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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