PowerPoint Presentation file4/16/2019 2 MNHPC 29th Annual Conference | April 14–16, 2019 •...

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MNHPC 29th Annual Conference | April 14–16, 2019 www.mnhpcconference.org

Interdisciplinary Care of Veterans with Post Traumatic

Stress Disorder (PTSD)

Quinn Kellerman PhD, LP

Kristopher Hartwig MD, MPhil

Minneapolis VA Health Care System


All planners, presenters, and authors have disclosed relevant

relationships with commercial interests and have no conflicts of interest to report.

DISCLOSURES

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• Describe Post Traumatic Stress Disorder (PTSD) and the

population that is at risk

• Correlate the prevalence of PTSD and the symptoms of dementia

• Identify strategies that each member of the Interdisciplinary Team can use to care for those at end of life with PTSD

OBJECTIVES


• 70 year-old veteran

• Metastatic prostate cancer involving the periorbital region of the left eye

• History of diabetes, TBI from motorcycle accident, PTSD related to

Vietnam combat experience, substance use disorder

• No history of dementia

• On home hospice and recently prescribed steroids to reduce the

periorbital swelling and associated pain

• Pain improves but agitation, impulsiveness, and angry outbursts

increase such that his wife can no longer care for him

• He is admitted to the hospital for medical and symptom management

Case Illustration: Mr. B


• Previously included under Anxiety Disorders; PTSD is now part of

a chapter for Trauma- and Stressor-Related Disorders in DSM-5

• Exposure to actual or threatened death, serious injury, or sexual

violence via:

Direct exposure

Witnessing the trauma

Learning that a relative or close friend was exposed to a

trauma

Indirect exposure to aversive details of the trauma, usually in

the course of professional duties (e.g., first responders,

medics)

DEFINITION: Post-Traumatic Stress Disorder

(PTSD)

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A = Exposure to a traumatic event or stressor

B = Persistent re-experiencing (nightmares, flashbacks, intrusive memories)

C = Avoidance of thoughts, feelings, events reminiscent of trauma

D = Negative cognitions & mood

E = Persistent symptoms of increased arousal not present before

F = Duration of symptoms > 1 month

G = Significant distress or impairment in social interactions, capacity to work or other important areas of functioning.

H = Not the physiological result of another medical condition, medication, drugs or alcohol

DSM-5 Diagnostic Criteria for PTSD

PTSD Brain

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National Comorbidity Study (Kessler et al., 1995)

• 50-60% exposure

• 56% men, 49% women exposed to >1 trauma

• 90% exposure in some high risk urban areas such as Detroit (Breslau

et al., 1998)

National Comorbidity Survey Replication (NCS-R; Kessler et al., 2005)

• Interviews from February 2001 – April 2003 of a nationally

representative sample of 9,282 Americans aged 18+ years

• PTSD was assessed among 5,692 participants using DSM-IV criteria

• Lifetime prevalence of PTSD among adult Americans was 6.8%.

GENERAL POPULATION: Trauma Exposure and

PTSD


National Vietnam Veterans Readjustment Study (NVVRS; Kulka et al., 1990)

• Interviews from November 1986 – February 1988 of 3,016 American Veterans representative of those who served during the Vietnam era

• Estimated lifetime prevalence of PTSD: 30.9% for men, 26.9% for women

• Of those who served in theater: 15.2% of men, 8.1% of women were diagnosed with PTSD at the time the study was conducted

Additional Statistics for Veterans

• New exposure measure and cross-check of NVVRS (Dohrenwend et al., 2006)

Estimated lifetime prevalence of PTSD: 19%

Current PTSD (11-12 years after war): 9.1 %, moderate impairment

• Gulf War Veterans: Prevalence of PTSD = 10.1% (Kang et al., 2003)

• 1,938 OEF/OIF service members: Prevalence of PTSD = 13.8% (Tanielian & Jaycox (Eds.), 2008)

VETERAN POPULATION: Trauma Exposure and

PTSD


• For chronic PTSD, it often looks like a continuation from young

adulthood

• For some older adults, symptoms of PTSD crop up after retirement or after developing a chronic medical condition

• Individuals may have subthreshold symptoms that do not meet

full criteria, yet still cause distress and/or disrupt life activities

• Late Onset Stress Symptomatology (LOSS; Davidson et al.,

2006)

PTSD in Older Adults

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• Phenomenon among older Veterans who were exposed to highly stressful war-zone events in their early adult years

• Since functioned successfully with no long-term history of chronic stress-related disorders

• Begin to experience combat-related thoughts, feelings, memories, and possibly distress as they confront the challenges of aging (e.g., retirement, bereavement, medical illness)

• Reaction can be less severe/debilitating than PTSD OR can be as distressing as early-onset PTSD

Late-Onset Stress Symptomatology (LOSS)


• Life review

• Normative aging changes trigger feelings related to earlier losses or trauma

• Role loss

• Medical problems

• Loss of autonomy/control

• Death of loved ones, cohort

• Feelings of helplessness, pain

• Cognitive losses may set the stage for some individuals

Late-Onset Stress Symptomatology (LOSS)


• Important to consider with our aging population

• PTSD has been associated with:

Poorer cognitive performance (e.g. reductions in learning, free and cued

recall, and recognition memory)

Altered chemical pathways in the body, leading to “accelerated brain

aging”

Increase heath care utilization due to multiple health problems

PTSD and Risk for Dementia

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Archival Dementia Risk Study (Yaffe et al., 2010)

• Veterans over the age of 55 with at least one visit to the VA

between 1997-2000, at least one follow-up visit between 2000

and 2007, and NO dementia diagnosis during the initial visit

(N = 181,093)

• 53,155 Veterans had a PTSD diagnosis during the initial period

(1997-2000) and 127,938 Vets with no PTSD diagnosis

PTSD and Risk for Dementia Among Veterans


• Veterans with PTSD were nearly twice as likely as those

without to develop dementia (HR 2.31)

• Results were the same when controlling for other factors:

Demographic variables (HR 2.28)

Medical comorbidities (e.g., diabetes, heart disease, cancer) (HR

2.21)

Psychiatric comorbidities (e.g., depression, substance abuse) (HR

1.84)

All combined contributors (HR 1.77)



Another study reviewed archival data for incidence and

prevalence of dementia in Veterans with PTSD (Qureshi et al., 2010)

• Veterans diagnosed with PTSD were twice as likely to be

diagnosed with dementia (any type) than Veterans without

PTSD (even those with combat exposure)

• Incidence (new cases) and prevalence (all cases) of dementia

were higher in the PTSD group than non-PTSD groups


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Regardless of the cause of dementia in persons with PTSD, a history of PTSD can continue to play a role in behavior after the onset of dementia

• Traumatic events seem “fresher”/more recent as dementia progresses

• Institutional environments can hold numerous triggers (e.g. Holocaust survivors, POWs)

• Learned coping responses and post-trauma life successes may be lost

• History of PTSD has been associated with increased agitation and behavioral disturbance in nursing home patients

Cognitive impairment may lower threshold for emotional response to triggers for PTSD symptoms and disinhibit problem behaviors

Interaction of PTSD and Dementia


• Is there anything about your military experience or other parts of your history that still bother you?

• Primary Care-PTSD Screen

• PTSD Checklist (PCL – Veteran and civilian versions)

• SPRINT

• Trauma Screening Questionnaire

• Clinician-Administered PTSD Scale (CAPS)

• Mississippi Scale for Combat-Related PTSD

• Impact of Events Scale

• SCL-90 PTSD Scale

• Self-Rating Inventory for PTSD (SRIP)

Assessment of PTSD


(If a traumatic event is identified)

In the past month, have you:

• Had nightmares about the event or thought about the event when you

did not want to?

• Tried hard not to think about the event or went out of your way to

avoid situations that reminded you of the event?

• Been constantly on guard, watchful, or easily startled?

• Felt numb or detached from people, activities, or your surroundings?

• Felt guilty or unable to stop blaming yourself or others for the event or

any problem the event may have caused?

Primary Care PTSD Screen (PC-PTSD-5)

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• Present assessments in printed format as well as reading information aloud to

increase understanding

Older Veterans may be hard of hearing and those with dementia may have

auditory processing deficits

• Minimize outside distractions (e.g., noises, interruptions)

• Recognize that some symptoms of PTSD may be difficult for older adults (or those

with dementia in particular) to understand

• Allow for breaks during assessment

• Do comprehension checks periodically by asking the patient to summarize in his or

her own words what you explained

• Take care not to talk down to the patient while making any necessary adjustments

in the process for dementia

• Collect collateral information from family or caregivers

Optimizing PTSD Assessment in Persons with

Dementia


• TV shows or movies related to event

• Being bathed (sexual trauma and/or intimacy issues)

• Gender or race/ethnicity of caregivers (e.g., sex of perpetrator)

• Smells (e.g., fires, certain foods)

• Sounds (e.g., songs, foreign languages, loud noises)

• Any apparent threat or physical touch

Possible Triggers for PTSD Symptoms in Care

Settings


• Exacerbation of distress and symptoms due to facing a life threatening illness

• Emotional responses resulting from normal life review (intense anxiety, anger, guilt, or sadness) – as one looks back on life, may bring up memories that are not pleasant and may have been avoided for a long time

• Avoidance symptoms Poor medical adherence

Impede ability for the doctor to engage in direct, problem-focused communication regarding care

• Refusal of care or excessive questioning of provider’s actions or distrust or authority

• Decreased social support of lack of caregivers as a result of social isolation and avoidance

5 Ways PTSD Presents at End-of-Life

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• PTSD affects pain, anxiety, sleep, and is associated with a

tendency for long-standing avoidance behaviors, co-morbid substance use

• More complex end-of-life trajectory suggested

• 5341 EOL veterans cases (Bickel et al., 2019)

8.7% have PTSD

Increased ICU, ED visits, full code status at EOL

Increased benzodiazepine, anti-psychotic, opioid use

PSTD and Inpatient End-of-Life Care in Veterans


• New environments

• Financial strain

• Functional losses (e.g., driving, self-care, physical and cognitive activities, independent living) and associated loss of control

• Diminished interpersonal resources (e.g., loss of social support)

• Fear and anxiety from cognitive loss

How Might Dementia Exacerbate PTSD

symptoms?


• Prolonged Exposure Therapy

• Cognitive Processing Therapy

• Relaxation Training

• Mindfulness-based approaches

Psychological Evidence-Based Treatments for

PTSD

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• Prazosin – may be useful for nightmares or other PTSD

symptoms in older adults

• SSRIs – may be helpful for avoidance, numbing, hyperarousal

symptoms, and nightmares

• Fluvoxamine, sertraline, nefazodone showed some efficacy in open label trials

• Benzodiazepines – have been used for anxiety/agitation, but

adverse side effects include cognitive impairment, falls,

sedation, respiratory problems, and dependence

Pharmacological Treatments for PTSD


Prolonged Exposure and Sertraline Trial [PROGrESS] (Rauch et al.,

2019)

• 223 veterans (Iraq/Afghanistan eras) with PTSD

• 3 treatment groups (6 months duration):

– Medication alone (sertraline)

– Prolonged exposure therapy (traditional best practice)

– Prolonged exposure therapy + medication

• All 3 groups improved significantly, none better than the other

– Active support for medication critical

– Take-home message: careful intervention helps

Comparison of Treatments: Medication vs. PE


• For those who are cognitively intact, psychological treatments focus reframing unhelpful thoughts, retraining brain to understand that perceived threats are not actual threats, regulating physiological arousal

• For those with dementia, they are more in tune with sympathetic nervous system responses and pick up on nonverbal/visual cues or interactions – this would be exacerbated with a comorbid diagnosis of PTSD

– Given inability to reframe thoughts and regulate emotions in the same way, interventions need to focus on family and interdisciplinary team understanding triggers, modifying environment, and attempting to eliminate any potential activators toward the behavior

Traditional Treatments not Effective with PTSD and

Dementia

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Demographics• 85 years old

• White male

• Divorced x3, widowed x1, 5 adult children

• Marine Corps Veteran, 100% Service Connected, Korean War

Education/Occupation• GED during military service

• Retired car salesman – Ford Motor Company

Diagnoses• Major Neurocognitive Disorder, Unspecified (likely Alzheimer’ disease with

cerebrovascular disease component)

• Comorbid major depression, severe PTSD related to combat trauma (70% Service Connected), OSA, CAD, pulmonary HTN, DMII

Case Illustration: Mr. Z Psychosocial History


Reason for Admission to VA:• Admission 1: Physical aggression in previous nursing home (slapped

staff member in the face when veteran attempting to elope)

• Admission 2: Several episodes of physical aggression toward residents in nursing home after 1st discharge from CLC

Family Involvement:• Estranged from 5 children

• Court-appointed guardian (veteran’s former hair dresser)

Barriers to Discharge:• Physically robust, strong

• Failed placement in several community facilities

Case Illustration: Mr. Z Additional Background


Known Activators: • Perceived threat toward self or others

• History of PTSD (leads to distorted thinking, hypervigilance)

• Other residents (lower functioning, perceived threat)

• Perceptions of others taking his belongings

Common Distressed Behaviors:• Physical aggression (toward staff and residents)

• Verbal aggression including threats of physical aggression

• Sexually inappropriate comments

• Confabulation and/or elopement attempts

Case Illustration: Mr. Z Behavioral Symptoms

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BEHAVIORAL INTERVENTIONS• Communication

• Validation

• Not arguing or pursuing tasks

• Allowing for refusal

• Redirecting conversation• Limit-setting

• Tone of voice

• Awareness of non-verbal signs of aggression

ACTIVITY• Distract with another staff approaching

• Offer alternative activity before pursued task

• Reminiscence, pleasant conversation

• Ambulation (walks)

• One-on-one attention

Overview of Treatments

PHARMACOLOGICAL TREATMENTS

• Previously trialed psychotropic

medications: venlafaxine, trazodone,

prazosin, melatonin, olanzapine, valproic

acid, zolpidem

• Current psychotropic medications:

escitalopram, aripiprazole (tapering),

divalproex, gabapentin, risperidone


UNDERSTANDING TRIGGERS

& ELIMINATE ACTIVATORS

• Get to know individual’s history• Improve awareness of increasing signs of

anxiety or agitation• Be aware of intrusion of personal space

(toileting, dressing, showering) and surprising someone (waking up or redirecting by touching)

• Avoid attempting to deescalate in the same way you would with someone who was cognitively intact

• Turn off television shows or movies that might be reminiscent of traumatic event

Interdisciplinary Team Care – We can all do this!

MODIFY ENVIRONMENT

(YOU + EXTERNAL)

• Provide safety reassurance

• Offer comfort and a supportive presence

• Refrain from correcting perceived reality and redirect/distract instead

• Provide adequate time for processing and understanding of cares

• Avoid cognitively challenging tasks

including asking a lot of questions

• Engage in pleasant conversation or

activities based on individual’s likes and dislikes


• Stage 1: Address short-term concerns (symptoms, social

supports)

• Stage 2: Enhance coping skills

• Stage 3: Treat specific trauma issues if time, cognition, and

prognosis allow

Stepwise Psychosocial Palliative Care for PTSD

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• Hyperglycemia treated, steroids tapered, other causes of

delirium ruled out

• Assessed as having moderate cognitive dysfunction/dementia

• Anger management a major focus

• Various medications tried, eventually clonazepam scheduled

seems helpful. Others did not.

• Returned home, died about 6 weeks later

Case Illustration: Mr. B

https://www.youtube.com/watch?v=uG3RG-aZLDc

https://www.ptsd.va.gov/


Bickel, K., Bailey, F.A., Kennedy, R., & Burgio, K. (2019). Examining relationship between post-traumatic stress disorder (PTSD) and inpatient end-of-life care in Veterans Affairs (VA). Journal of Pain and Symptom Management, 57(2), 418. doi: 10.1016/j.jpainsymman.2018.12.137.

Davidson, E.H., Pless, A.P, Gugliucci, M.R., et al. (2006). Late-life emergence of early-life trauma: The phenomenon of late-onset stress symptomatology among aging combat veterans. Research on Aging, 28, 84-114. doi: 10.1177/0164027505281560.

Dohrenwend, B.P., Turner, J.B., Turse, N.A., Adams, B.G., Koenen, K.C., & Marshall, R. (2006). The psychological risks of Vietnam for U.S. veterans: A revisit with new data and methods. Science, 313(5789), 979-982. doi: 10.1126/science.1128944.

Kang, H.K., Natelson, B.H., Mahan, C.M., Lee, K.Y., & Murphy, F.M. (2003). Post-traumatic stress disorder and chronic fatigue syndrome-like illness among

Gulf War veterans: A population-based survey of 30,000 veterans. American Journal of Epidemiology, 157(2), 141-148.

Kessler, R.C., Berglund, P., Delmer, O., Jin, R., Merikangas, K.R., & Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV

disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6): 593-602.

Kessler, R.C., Sonnega, A., Bromet, E. Hughes, M., & Nelson, C.B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of

General Psychiatry, 52(12), 1048-1060.

Kulka, R.A., Schlenger, W.A., Fairbanks, J.A., et al. (1990). Trauma and the Vietnam War generation: Report of findings from the National Vietnam Veterans

Readjustment Study. New York: Brunner/Mazel.

Rauch, S.A.M., Kim, H.M., Powell, C., et al. (2019). Efficacy of prolonged exposure therapy, sertraline hydrochloride, and their combination among combat

veterans with posttraumatic stress disorder: A randomized controlled trial. JAMA Psychiatry, 76(2), 117-126. doi: 10.1001/jamapsychiatry.2018.3412.

Tanielian, T. & Jaycox, L. (Eds.). (2008). Invisib le Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery .

Santa Monica, CA: RAND Corporation.

Qureshi, S.U., Kimbrell, T., Pyne, J.M., et al. (2010). Greater prevalence and incidence of dementia in older veterans with posttraumtic stress disorder. Journal

of the American Geriatrics Society, 58(9), 1627-1633. doi: 10.1111/j.1532-5415.2010.02977.x.

Yaffe, K., Vittinghoff, E., Lindquist, K., et al. (2010). Post-traumatic stress disorder and risk of dementia among U.S. veterans. Archives of General Psychiatry,

67(6), 608-613. doi: 10.1001/archgenpsychiatry.2010.61.

REFERENCES

https://www.youtube.com/watch?v=uG3RG-aZLDc

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