Download Consideration of Military Culture

Melissa Kremer, Psy.D.
Boise VAMC
Objectives
Learn: Understand symptoms of PTSD
Learn: How to identify specific end of
life challenges Veterans may face
Learn: Strategies for working with
Veterans with PTSD in hospice and
palliative care
Why Veterans?
Veteran Statistics in Idaho
Total Veterans: 132,395
Wartime Vets: 104,181
Gulf War: 43,622
Vietnam Era: 48,385
Korean Conflict: 10,816
World War II: 5,461
Peacetime: 28,214
Female: 9,683
Male: 122,712
Numbers for FY 2014 www.va.gov/vetdata
Veteran Statistics in Oregon
Total Veterans: 331,632
Wartime Vets: 247,359
Gulf War: 85,923
Vietnam Era: 123,516
Korean Conflict: 29,356
World War II: 18,357
Peacetime: 84,273
Female: 28,483
Male: 303,149
Numbers for FY 2014 www.va.gov/vetdata
Veteran Statistics in Washington
Total Veterans: 603,623
Wartime Vets: 459,831
Gulf War: 208,006
Vietnam Era: 208,485
Korean Conflict: 44,052
World War II: 24,824
Peacetime: 143,791
Female: 64,392
Male: 539,231
Numbers for FY 2014 www.va.gov/vetdata
Veteran Statistics in Montana
Total Veterans: 99,946
Wartime Vets: 75,312
Gulf War: 31,210
Vietnam Era: 35,105
Korean Conflict: 7,831
World War II: 3,987
Peacetime: 24,334
Female: 8,445
Male: 91,201
Numbers for FY 2014 www.va.gov/vetdata
Veteran Deaths
Nearly 680,000 Veterans die each year
Less than 4% of Veterans die in VA facilities
Over 1 million total Internments at National
Cemeteries between FY2000-FY2014-numbers
increasing yearly
www.va.gov/vetdata
PTSD
There have been some changes in the most
recent publication of DSM-5 in terms of
PTSD.
It’s now grouped with other disorders in a
category called Trauma and StressorRelated Disorders
Remember that PTSD has various causes
across the life span.
Changes in Criterion A: trauma exposure
PTSD
Four symptom “buckets”
• Intrusion symptoms
• Persistent avoidance of stimuli associated with
the trauma
• Negative alterations in cognitions and mood that
are associated with the traumatic event
• Alterations in arousal and reactivity that are
associated with the traumatic event
PTSD Screening Tool
In your life, have you ever had any experience that was so frightening,
horrible, or upsetting that, in the past month, you:
Have had nightmares about it or thought about it when you did not want to?
YES / NO
Tried hard not to think about it or went out of your way to avoid situations
that reminded you of it?
YES / NO
Were constantly on guard, watchful, or easily startled?
YES / NO
Felt numb or detached from others, activities, or your surroundings?
YES / NO
PTSD Assessment Tools
The National Center for PTSD recognizes almost 70 measures
used specifically to assess for PTSD.
Clinician-Administered PTSD Scale for DSM-5 (CAPS-5)
Combat Exposure Scale (CES)
Mississippi Scale for Combat-Related PTSD (M-PTSD)
PTSD Checklist for DSM-5 (PCL-5).
In addition to more comprehensive assessment measures,
including cognitive and personality functioning measures.
PTSD with older populations
Aging is not a process that begins at the end of life, but is life-long.
It has been speculated that later-life factors can trigger additional
PTSD distress/symptoms.
Research has shown that individuals with combat exposure were
more susceptible to health decline. Increasing levels of combat
exposure and lower rank were associated with poorer quality of life
across domains.
As we age, there are natural decreases in memory skills. This lowers
the ability to manage distress.
Additionally, when you combine avoidance, mistrust and increased
health concerns, you get a population who might not present for
needed care, or feel “forced” into care by loved ones that they do not
think they need.
Chatterjee et al, (2009), Ikin et al (2009)
PTSD and Dementia
Veterans with PTSD are nearly twice as likely to develop
dementia. Note that the studies used administrative codes to
determine PTSD and dementia status and the sample was
predominantly (96.5%) male. As of yet, little is known about the
relationship between PTSD and dementia in women.
Substance use may increase risk for both PTSD and dementia.
In one study, residents of a Community Living Center (CLC)
with substance use problems had higher rates of PTSD,
dementia, and physical problems.
Qureshi et al (2010), Yaffe et al (2010) & Lemke et al (2010)
PTSD and Dementia
How does dementia affect coping abilities?
Is assessment for PTSD with dementia
different?
What is the difference between delirium
and flashbacks?
Military Culture
Military training encourages toughness, courage
and denial of emotions.
“No pain, no gain”
Fear, pain and emotion are a sign of weakness
Stoicism is the ability to conceal emotions and
outwardly seem indifferent to hardship, pain and
grief
Cultural Differences
Hospice
Military
•Interdependence
• Dependency
•Reconnect with others
•Hierarchical
organization
•Life review, reminisce,
openly grieve
•Encourage selfdetermination and
choice
•Culture of stoicism;
downplay suffering
•Give orders, follow
orders
PTSD and Dying
PTSD can complicate the dying process in several ways:
The threat of loss of life may mimic the original trauma
When key memories are trauma related, the normal
process of life review can lead to intense anger,
sadness or guilt.
Veterans with PTSD are good at avoiding, sometimes
everything.
Stoicism may lead to under-reporting
symptoms/pain/fear.
Distrust of authority can lead to excessive questioning
and refusal of care.
Veteran may have limited or no social support system.
Clinical PTSD Treatment
Cognitive Behavioral Therapy (CBT)
Cognitive Processing Therapy (CPT)
Prolonged Exposure (PE)
Eye Movement Desensitization and Reprocessing
(EMDR)
Acceptance and Commitment Therapy (ACT)
Supportive Therapy-Telehealth
Groups-PTSD, Insomnia, Pain
Interventions
LISTEN. Don’t force the conversation, especially if this is something
they have never discussed.
Understand, acknowledge and accept the Veteran’s pain, anger,
shame, guilt, fear and helplessness. Also understand that might feel
this is necessary for them to hold on to, and “suffer” with. Avoid
assumptions.
Encourage forgiveness (of self, of others, religious-if important to
Vet)
Educate the family on PTSD symptoms-consider the dynamics if a
Veteran has been distant/avoidant of family for many years
Offer the support of social work, psychology, psychiatry, Chaplain.
They can assist with relaxation techniques, guided imagery, etc
Consider psychotropic medications to assist in symptom alleviation
Psychopharmacological Interventions
In order to help Veterans feel more comfortable, allow them as much
control of the development of the care plan as possible.
For Veterans with at least one month life expectancy,
antidepressants (Sertraline, Mirtazapine, Fluoxetine) can help
manage symptoms.
For Veterans expected to only live a short time, the focus should be
on alleviation of distress and enhanced comfort. Benzodiazepines or
neuroleptics may help with agitation, hyper-arousal or
anger/irritability. Lithium, clonidine and neuroleptics may help with
intrusive symptoms. Risperidone may help with aggression and
psychosis. Olanzepine may help with psychotic episodes.
Considerations of co-occuring disorders, such as dementia or
substance abuse
Interventions
Try to avoid using alarms or restraints, as that could further agitate
Veterans.
Consider the positioning of the bed in the room, especially in regards
to the door. Many Veterans feel boxed in, and get very agitated if
they feel their “escape routes” are blocked.
Avoid loud, startling noises.
Don’t touch the Veteran if they are sleeping, especially if they appear
to be having a nightmare. Call out their name first. Veterans may
actually fear sleeping because of nightmares.
Interventions
For some WWII, Korean conflict and Vietnam era Veterans, caregivers of
Asian descent may trigger PTSD symptoms. Persian Gulf and OEF/OIF/OND
Veterans may be triggered by individuals of Middle Eastern descent.
Grounding in reality may not be effective. Create a safe place for them.
Veterans-especially of the older generation-are often more hesitant to
reveal military sexual trauma (MST). Male or female caregivers may be
triggering depending on the sex of the perpetrator of the trauma. Being
bathed or changed (which leaves people feeling vulnerable) could also be
triggering.
Sights, smells, tastes, sounds, touch, etc are all powerful triggers-movies, TV
shows, military gear, patriotic clothing, wounds, food smells, etc
“Behavioral Problems” are often an attempt at communication rather than
manipulation.
Interventions
Examine the companion animal/service dog policy of your
institution. Often a companion animal has been a major
source of comfort, and way to alleviate anxiety for
Veterans.
Veterans may want to tell their story, and their family
may have questions. Recording the Veteran talk about
their experiences, or helping them create a memory book
may be powerful. If a Veteran has medals, but never got
them, directions on how to obtain medals can be found
online at the National Archives website:
http://www.archives.org
Express appreciation for their service, male or female,
regardless of era.
What do we do as staff??
Increase your own knowledge about PTSD and symptomology
Increase your distress tolerance-many Veterans I work with are so scared to
share their history, as they feel they will be shamed. We tend to respond
with horror to many things, and an individual may internalize that response.
SELF CARE
Use your team model for patient care, especially if the patient requires a
great deal of energy.
Sources
Chatterjee, S., Spiro, A., King, L., King, D. & Davison, E. (2009) Research on
Aging Military Veterans: Lifespan Implications of Military Service. PTSD
Research Quarterly, 20(3), 1-7.
Davison, E., Pless, A., Gugliucci, M., King, L., King, D., Salgado, D., Spiro, A. &
Bachrach, P. (2006) Late-Life Emergence of Early-Life Trauma: The Phenomenon
of Late-Onset Stress Symptomatology Among Aging Combat Veterans. Research
on Aging, 28(1), 84-114.
Ikin, J.F., Sim, M.R., McKenzie, D.P., Horsley, K.W.A., Wilson, E.J., Harrex, W.K.,
et al. (2009) Life Satisfaction and Quality in Korean Veterans Five Decades After
War. Journal of Epidemiology and Community Health, 63, 359-365.
Karner, T.X. (2008) Posttraumatic Stress Disorder and Older Men: If Only Time
Healed All Wounds. Generations, 32(1), 82-87.
Lemke, S., & Schaefer, J. A. (2010). VA nursing home residents with substance
use disorders: Mental health comorbidities, functioning, and problem behaviors.
Aging & Mental Health, 14, 593-602. doi: 10.1080/13607860903586169
Sources
Litz, B., Stein, N., Delaney, E., Lebowtiz, L., Nash, W., Silva, C. & Maguen, S.
(2009) Moral Injury and Moral Repair in Veterans: A Preliminary Model and
Intervention Strategy. Clinical Psychology Review, 29, 695-706.
National Center for PTSD www.pstd.va.gov
Qureshi, S. U., Kimbrell, T., Pyne, J. M., Magruder, K. M., Hudson, T. J.,
Petersen, N. J., Yu, H., Schultz, P. E., & Kunik, M. E. (2010). Greater
prevalence and incidence of dementia in older Veterans with posttraumatic
stress disorder. Journal of the American Geriatrics Society, 58, 1627-1633. doi:
10.1111/j.1532-5415.2010.02977.x
www.wehonorveterans.org
www.va.gov/vetdata
Yaffe, K., Vittinghoff, E., Lindquist, K., Barnes, D., Covinsky, K. E., Neylan, T.,
Kluse, M. & Marmar, C. (2010). Posttraumatic stress disorder and risk of
dementia among US Veterans. Archives of General Psychiatry, 67, 608-613.
doi: 10.1001/archgenpsychiatry.2010.61