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Although lifetime exposure to potentially traumatic events among older adults is fairly high, rates of full-blown post-traumatic stress disorder (PTSD) are estimated at about 4.5%, a rate lower than that for middle-aged and young adults. Nevertheless, PTSD seems to be an under-recognized and under-treated condition in older adults. Assessment and treatment can be challenging in this population for various reasons, including potential cognitive or sensory decline and comorbid mental and physical disorders. This article provides highlights of the empirical research on PTSD in late life, including information on its effects on cognition and physical health. The bulk of this piece is spent on reviewing the theory, description of, and efficacy for an evidence-based psychotherapy, Prolonged Exposure (PE), for PTSD. A detailed successful application of PE with an older veteran with severe, chronic PTSD in the Department of Veterans Affairs Health Care System is presented. Evidence-based psychotherapy for PTSD can be safely and effectively used with older individuals.
Trauma and post-traumatic stress disorder (PTSD) have been referred to as hidden in the lives of older adults, meaning that related clinical information is not typically recognized, acknowledged or shared by the older patient.
Though there is comparatively less research on trauma and PTSD in older as opposed to middle-aged and younger adults, clinical lore indicates that older adults may not recognize or admit to trauma-related difficulties and healthcare professionals may under recognize or under treat theseconditions. Highlights of the empirical research on PTSD in late life, including information on its effects on cognition and physical health, are presented to better understand special considerations in this population (for more comprehensive overviews, see Cook et al.
in: Sorocco K.H. Lauderdale S. Cognitive Behavior Therapy with Older Adults: Innovations Across Care Settings. Springer Publishing Co,
New York, NY2011: 189-217
). Addressing the needs of traumatized older populations involves accurate assessment and evidence-informed treatment. Thus, the theory, description of, and efficacy for an evidence-based psychotherapy (EBP) for PTSD, Prolonged Exposure
(PE), are presented to help mental health providers understand the nuances in delivering this intervention as well as its potency in older adults.
PTSD in Older Adults
Data from a nationally representative sample show that older adults experienced significantly fewer potentially traumatic experiences than younger and middle-aged adults.
In a large epidemiological investigation, the most common self-identified “worst” stressful events reported by older adults who reported exposure to trauma but did not have full syndromal PTSD were unexpected death or serious illness or injury to someone close.
Psychiatric comorbidity of full and partial posttraumatic stress disorder among older adults in the United States: results from wave 2 of the national epidemiologic survey on alcohol and related conditions.
The stressor criterion of “unexpected death of a loved one” was expected to capture violent death through murder, assault, combat, or terrorist attack, and in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
Older adults diagnosed with full PTSD, compared with those who had been exposed to a traumatic event but had no PTSD, more often reported their own serious illness, other traumatic events they experienced themselves, intimate partner violence, and sexual assault as their most distressing event.
Psychiatric comorbidity of full and partial posttraumatic stress disorder among older adults in the United States: results from wave 2 of the national epidemiologic survey on alcohol and related conditions.
Psychiatric comorbidity of full and partial posttraumatic stress disorder among older adults in the United States: results from wave 2 of the national epidemiologic survey on alcohol and related conditions.
A separate study found that older adults who experienced childhood adversity had higher odds of having not just PTSD, but mood, other anxiety, and personality disorders in later life.
Age-related differences in rates of PTSD may be due to older adults' inclination to express mental health difficulties as somatic concerns or reluctance to acknowledge such problems due to perceived stigma (see Thorp et al.
Prolonged exposure therapy for older combat veterans in the veterans affairs health care system.
in: Sorocco K.H. Lauderdale S. Cognitive Behavior Therapy with Older Adults: Innovations across Care Settings. Springer Publishing Co,
New York, NY2011: 421-442
for further discussion). There has been concern that some older adults may have experienced trauma but do not recognize the potential negative effects or disclose these experiences to healthcare providers. This may partly be because for the current cohort of older adults, trauma that occurred before middle adulthood preceded the 1980 introduction of PTSD into the diagnostic nomenclature. This suggests that many older adults were not diagnosed with PTSD when symptoms were acute, and thus older adults themselves may not link their current symptoms to traumatic events that occurred earlier in life. Lower prevalence rates of PTSD in older individuals may also reflect a form of survivor bias, in that those with PTSD may be less likely to survive into late adulthood. In addition, healthcare providers may not recognize symptoms as the result of traumatic events or may be unsure of how to proceed with an older population in regards to formal assessment and treatment.
There are additional negative consequences of trauma and PTSD in older adults, ranging from comorbid psychiatric disorders to physical and cognitive health problems. Data from three aggregated nationally representative samples indicated that older adults with chronic PTSD were three times more likely to have any disability (e.g., self-care, mobility, cognition) than were those with no PTSD.
Being exposed to a traumatic event is associated with adverse physical health consequences across a continuum of outcomes that range from self-reported physical symptoms to physician-diagnosed healthcare disorders (for review see Schnurr
Older adults with PTSD generally perform more poorly across a range of cognitive measures, particularly processing speed, learning, memory, and executive functioning as compared to older adults without PTSD.
Similarly, in a sample of over 10,000 veterans aged 65 years and older, those with PTSD had almost twice the odds of developing dementia compared to those without PTSD.
reported that there was increased medical comorbidity among several targeted conditions known to be associated with normal aging (e.g., cardiovascular disease, type 2 diabetes mellitus, gastrointestinal ulcer disease, and dementia). Furthermore, PTSD was often associated with premature biological aging and earlier mortality. There is some caution, however, against generalizing evidence on the relationship between PTSD and cognitive impairment based on veterans to a wider population.
The negative effects of PTSD on older adults' psychiatric and medical comorbidity, including cognition and cardiovascular functioning, is profound. Thus, untreated psychological trauma and PTSD are a public health problem. There is a need to utilize effective EBPs with this population.
PTSD Treatment
Several cognitive-behavioral therapies (CBTs), namely, PE, Cognitive Processing Therapy
All three are trauma-focused treatments, meaning they involve the patient coming into contact with traumatic material whether it be through detailed enumeration or the challenging of cognitions related to the traumatic event or one's subsequent reaction.
PE is the most studied treatment for PTSD, and it shows particular promise with older adult populations. Based on the theory of emotional processing,
PE is built on a foundation that posits that fear structure (e.g., relationship between conditioned stimulus and unconditioned stimulus expectancy) is represented in the memory by three features: feared stimuli (e.g., fireworks, unfamiliar noise), fear-based physiological responses (e.g., increased heart rate, sweating), and construal of meaning about the stimuli and response (e.g., “We're under attack”, “We're in danger”). It is believed that PTSD results when fears are generalized to all stimuli and responses, creating a view of the world as constantly dangerous and the individual as helpless or incompetent in it. When stimuli become inaccurately perceived as dangerous, or the meaning construed from stimuli or response are inaccurately perceived as threatening, the result can be a pathological, overly intense, response that can interfere with daily functioning. PE therapy provides a framework to activate the fear structure without feared outcomes, provides the opportunity to incorporate in new information, allows one to distinguish between traumatic events and memory of traumatic events, and gives the opportunity to reevaluate cognitions, which together challenge the existing fear structure that is resulting in PTSD symptoms.
PE is typically delivered in 8 to 15 90-minute sessions, delivered 1–2 times per week. It consists of four components: psychoeducation, breathing retraining, and imaginal and in vivo exposure.
Psychoeducation includes the treatment rationale, general information about PTSD, an explanation of common reactions to trauma, and discussion about an index trauma judged to be the most upsetting. Breathing retraining is taught as a means of reducing anxiety to allow for engagement in necessary therapeutic tasks. Imaginal exposure involves the repeated recounting out loud by the client of the details of their most disturbing traumatic event. This part is typically conducted with the client's eyes closed for 30–60 minutes, using present tense detailed descriptions of the event, as well as the client's related thoughts and feelings. In vivo exposure is used between therapy sessions as a means of bringing the client into contact with situations, places, or objects that have been avoided following the trauma.
There has been some clinical concern expressed in the literature that trauma-focused interventions, particularly PE, may be harmful or counterproductive in traumatized older adults because of a potential to increase physiological arousal and decrease cognitive functioning among those who may have comorbid physical or cognitive conditions.
Nonetheless, hyperarousal is hallmark of PTSD and thus older adults with PTSD are regularly tolerating these symptoms. Moreover, arousal is an expected marker of emotional engagement with traumatic material in exposure therapies. There has also been some apprehension that PE may cause symptom exacerbation leading to premature termination of treatment. In a review of 25 controlled studies of CBT for PTSD for adults, however, no difference was found in dropout rates among exposure and other CBTs, suggesting that PE may not be less tolerable than alternate CBT approaches.
found that all the case studies and treatment outcome studies utilizing exposure therapy (e.g., imaginal exposure only; in vivo exposure only; full, manualized PE) reported at least some effectiveness in ameliorating symptoms related to trauma. One of the larger treatment outcome studies
showed a substantial benefit from PE for older male veterans treated nearly 40 years after combat. Although two of the exposure-based studies noted an increase in symptoms before patient improvement, no study reported long-term adverse physiological or cognitive effects despite the inclusion of participants with a heart condition, dementia, comorbid major depression, and panic disorders.
The empirical literature on adults' preferences for trauma treatment indicates that many participants in analog studies (i.e., non-clinical samples in which participants are asked to imagine what treatment they would choose) as well clinical samples of individuals with trauma histories or PTSD had strong preferences for exposure, particularly PE over medication and other psychotherapies.
Thus taken together the acceptability and tolerability of PE in older adults appears warranted. It also seems reasonable for a mental health provider to proceed with appropriate caution with use of PE and monitor older adults considered at elevated risk from high arousal, such as those with serious cardiac or respiratory problems. One suggestion for managing potential complications is to remain in consultation with the older adults' primary physician.
The following is a case illustration that demonstrates the effective use of PE with an older Vietnam veteran with severe, chronic PTSD.
Case Illustration
Mr. X is a 67-year-old divorced Caucasian Vietnam combat veteran with severe, chronic PTSD who had been participating in outpatient group programming several times per week over the past year. In response to an anniversary date of a war-related experience, he reported an increase in PTSD symptoms and a decline in functioning and he requested a more intensive level of treatment. He was referred and subsequently admitted to a U.S. Department of Veterans Affairs (VA) PTSD Residential Rehabilitation Program (PTSD-RRTP).
The VA provides a continuum of care options for veterans diagnosed with PTSD, and one segment along this continuum is residential care in the form of PTSD-RRTPs housed in or affiliated with VA medical centers. Veterans reside in these programs for weeks to months, and though the format and structure of these programs varies,
Residential treatment for posttraumatic stress disorder in the Department of Veterans Affairs: a national perspective on perceived effective ingredients.
all provide a more intensive level of care than outpatient treatment. Mr. X was admitted to a 3-month residential PTSD-RRTP that provides individual EBPs for PTSD and clinical case management in addition to medication management, psychoeducation, in vivo outings, peer support, and symptom-focused and coping skills groups.
Prior to his admission to the PTSD-RRTP, Mr. X had been in numerous treatment programs, ranging from inpatient to outpatient levels of care, over several decades with minimal clinically significant reductions in PTSD symptoms. The vast majority of his prior treatment focused on coping skills related to substance use, however, and the veteran attended one residential treatment program that worked to provide psychoeducation and skills training to better manage his PTSD symptoms approximately 20 years ago. Of note, he had not engaged in a trauma-focused EBP for the treatment of PTSD. He expressed no connection with his former wife or children but some connection with his siblings. He reported compliance in taking his psychiatric medications (i.e., sertraline, trazodone) in an effort to stabilize his mood and PTSD symptoms. He also was taking medication to manage his diabetes, chronic pain, and cholesterol.
Upon admission to the PTSD-RRTP, Mr. X met criteria for the following mental health diagnoses: PTSD, alcohol use disorder, cannabis use disorder, unspecified depressive disorder, and past cocaine use disorder (in remission 7 years). His self-report score on the PTSD Checklist for DSM-5
(PCL-5; measure range is 0–80, higher scores indicate greater PTSD symptom severity) was 40, indicating a moderate level of PTSD symptom severity. However, the veteran reported that he thought that this was not an accurate assessment of his symptoms because he did not want to “seem like I was complaining.” He explained that he was following the mission of the Marine Corps to not “complain.” A discussion ensued about the importance of truthfully representing PTSD symptoms to ensure more precise monitoring of his progress in and response to treatment.
At admission, his self-report score on the Patient Health Questionnaire
(WHOQOL-BREF) overall quality of life rating was good (score: 4). Consistent with Mr. X's underreporting on the PCL-5, these self-report scores were viewed by the treatment team as incongruent with his presentation and thus another example of the veteran's effort to “not complain.”
Mr. X met with a licensed clinical psychologist (EM) to discuss two EBP options: PE and CPT. During this meeting Mr. X was shown brief whiteboard videos developed by PTSD experts at the National Center for PTSD for both treatments. Mr. X and his therapist then engaged in a conversation regarding each protocol (e.g., overview and rationale of treatment, number and length of sessions, homework requirements, and expected efficacy). Mr. X chose to participate in PE because “that is the one I want to do least and I'm here to get better.”
Sessions 1 and 2
During his first session, Mr. X was provided with a digital recorder (to record sessions for his own use as part of homework) and began his engagement in weekly PE sessions. Mr. X's therapist reiterated the overview of and treatment rationale for PE. She explained the four components of PE with particular emphasis on the two most potent procedures thought to decrease PTSD symptom: imaginal and in vivo exposure. After describing these aspects of treatment in full detail, she explained that in therapy Mr. X would confront his distressing memories and reminders in order to facilitate the “processing” of the trauma. In essence, this means the patient is encouraged to consciously link emotional experiences in response to memories, putting these emotions into words and discussing the experience with the therapist. Mr. X's therapist further reiterated that, over time, Mr. X would learn these memories and reminders were not dangerous and that his anxiety/distress would decrease after repeated and prolonged confrontation.
During a structured trauma interview, Mr. X disclosed many traumatic events throughout his lifetime, including multiple combat-related experiences as well as civilian trauma. He worked to identify the trauma that was currently most distressing to him, and focused on a combat trauma in which he was captured by the North Vietnamese Army while on patrol in Vietnam. He asked appropriate questions (e.g., how could a treatment like PE help after it had been so long since the trauma; how could talking about the trauma repeatedly be helpful) and was skeptical of how effective it would be for him. Mr. X's psychologist reiterated the hypothesized underlying mechanisms of PE, that by talking about the trauma repeatedly, Mr. X would be able to fully experience the memory and associated feelings which helped him accept and not live in fear of the memory. At the end of session 1, Mr. X's therapist taught him a breathing retraining technique to help him learn how to breathe slowly and thus relax. Part of Mr. X's homework was to read a rationale for treatment handout and listen to the audiotape of the session daily.
During session 2, Mr. X learned about common reactions to trauma and spent time discussing the way PTSD has impacted his life. He discussed his difficulty listening to recorded session 1 and that he did not want to “complain.” He also reflected that he was surprised by how much he shared about his trauma history during the first session.
Mr. X and his therapist then constructed an in vivo hierarchy of avoided stimuli and situations. The list was long and included things that were directly related to his combat trauma as well as things which now evoked anxiety through the generalization of fear such as talking with peers and family (in person and on the phone), spending time with family, sitting with his back to the door, spending time outdoors, going out to a shopping area, watching the news, reading the news, being in a room with another person, and riding in the elevator. The therapist introduced the Subjective Units of Distress Scale
(SUDS; range: 0–100; 0 = no distress or discomfort; 100 = most distress and discomfort ever) and explained that this would serve as an emotional thermometer to how well Mr. X was doing through the imaginal exposure portion of the sessions as well as during her in vivo homework assignments. They then worked collaboratively to assign a SUDS rating as to how much each would elicit distress or discomfort in Mr. X if he were to engage in it right now. After, the therapist discussed how Mr. X would systematically and gradually approach these feared but otherwise safe objects and situations with the goals of reducing his fear. His therapist told him that it is normal to feel uncomfortable doing previously avoided activities or remembering the events of Vietnam.
Over the next week, Mr. X was asked to review the in vivo list of avoided situations to see if there were any other things that needed to be added to the list and to practice two in vivo exposures daily throughout the week. He was instructed to remain engaged in the in vivo exposures until his level of distress and discomfort decreased to a tolerable SUDS level (e.g., lowest SUDS during an exposure).
Sessions 3–8
At the third session, Mr. X reported that he was extremely anxious before coming and had thoughts about not attending the appointment. During this session, Mr. X completed his first imaginal exposure for 45 minutes without interruption. Imaginal exposure involves repeated, detailed narration of the traumatic memory while periodically reporting in-session SUDS levels. Mr. X was instructed to close his eyes and describe his experiences in combat in the present tense with as much sensory information as he could remember. SUDS were taken every 4–5 minutes during the imaginal exposure portion of the session. The therapist praised Mr. X for attending the session as well as for his bravery in facing his traumatic memories. This session and each subsequent session consisted of reviewing the homework from the previous week, reassessing and adjusting targeted in vivo exposures, imaginal exposure (approximately 30–45 minutes each session), and reviewing his thoughts, feelings, and experience during imaginal exposure.
Over the next five sessions, Mr. X continued to engage in imaginal exposure during sessions. His therapist gently reminded him to engage in the trauma memory by keeping his eyes closed, telling his experiences in the present tense, and recalling as many sensory details as possible. Initially during the imaginal exposure sessions, Mr. X was extremely fidgety and restless, rocking in his chair and humming. The humming would increase when he was triggered (reminded by a cue about the memory) or was generally uncomfortable with the content of the discussion. He described the humming as a distraction from urges to drink. As treatment progressed, the veteran was visibly less restless and more able to remain in his chair without rocking.
Mr. X actively listened to audiotapes of each session at least one time since the previous session as well as listened to the audiotape of his imaginal exposure at least once a day and rated his SUDS (before, after, and peak). He continued to practice his in vivo exposure homework daily and completed SUDS ratings for each exposure.
Sessions 9–12
The imaginal exposure in sessions 9–11 focused on one particular “scene” within the memory, referred to as the “hot spot” of the trauma, which continued to be the most distressing. At session 9, the veteran stated he felt he was not as distressed by the previously identified traumatic event, and he requested to focus on another traumatic event during the imaginal exposure. Although more than one traumatic memory is sometimes addressed in PE, this veteran was encouraged to stay focused on the current trauma until his distress decreased even more. The rationale for this in PE is that the benefits of focusing on one event (e.g., learning that the memories are not physically harmful and that the distress does not last forever) often generalize to other traumatic memories.
Through continued focus on the traumatic event, the veteran was able to connect with feelings and thoughts related to interpersonal interactions (e.g., isolation from people he cared about because he did not believe he had a meaningful role in their lives; choosing employment options where he would have minimal interactions with others; thinking if people knew what happened in Vietnam they would judge him harshly) and choices he had made in his life (e.g., abuse of substances to numb his feelings; loss of purpose in life resulting in homelessness; not taking care of his physical health). At the end of the imaginal exposure component of the sessions, the veteran would explore what the experience was like for him. As he continued to engage in imaginal exposure and the discussions with his therapist thereafter, he understood himself and his reactions better. He was able to make the connections about his questioning of people and their commitment to him related to parallels in his trauma and the impact these beliefs had on interpersonal relationships since his trauma. For example, “They left me there. You never leave a Marine behind,” related to questions he had about his own self-worth and commitment others had to him as well as his commitment to others. He was able to articulate and examine cognitions related to what he did to stay alive. He was able to identify and connect with feelings of anger, disappointment, blame, guilt, and sadness as well as hope, relief, and gratitude. The veteran made efforts to access social support in his life again because he determined that he was “someone who has something to offer others.” He was able to recognize that he could trust people again including himself, that he was stronger since he asked for help, yearned for companionship, and that he had meaningful contributions to make in relationships, especially with his ex-wife and children.
Mr. X continued to experience overall sequential decreases in his SUDS scores with each session. During the final stage of treatment, progress was reviewed by reflecting on changes in PTSD symptom measures, observation, and subjective verbal report. Also, challenges and successes were discussed and encouragement was provided for the veteran to develop greater independence from the provider with in vivo exposures (e.g., coming up with his own exposures). PE was concluded at session 12 as the veteran reported his distress related to the traumatic memory was not severely impacting his functioning and that he experienced significantly less distress during the imaginal exposure. When reflecting on the treatment, he stated, “This gave me the confidence to know that I deserve more … it gave me the confidence to believe in myself and allowed me to see another part of myself.” At the final session, relapse prevention strategies (e.g., role of avoidance, predicting times of stress and impact on PTSD symptoms, ways to maintain gains) were identified and discussed.
The PCL-5 at the end of treatment was 27, a 13-point decrease, consistent with a reliable and clinically meaningful change. At the conclusion of treatment, Mr. X no longer met full criteria for PTSD. The veteran had clinically meaningful changes in re-experiencing negative cognitions and mood symptoms. In particular, he reported fewer nightmares; decreased flashbacks; less frequent intrusive memories; few cognitions related to anger, self-blame, and guilt; as well as lower arousal symptoms (continually scanning his environment for threats, startling easily). He shared that “I no longer have to be on guard all the time.” See Figure 1 for more details related to his PCL-5 throughout treatment. He reported that his memory of that fateful day was now clearer and less distressing.
Figure 1Mr. X's four PCL-5 cluster scores throughout treatment.
Additionally, the veteran reported it was helpful to talk about the trauma in the format that PE recommends because he felt heard, and recognized that someone was interested and cared about him (which was achieved through non-judgmental reflection, feedback, and active listening). He was able to recognize that what he says mattered and when listening to the recorded imaginal sessions, he was able to hear himself and connect with himself in a more compassionate manner rather than being critical and judgmental. He no longer feared the emotions and thoughts the trauma triggered. He was able to accept the trauma for what happened and subsequently was able to move forward in life recognizing what he does matters and that he is valued as an individual.
At discharge from the PTSD-RRTP, his PHQ-9 score was 11; a 2-point increase since admission (continuing to indicate mild depression severity) and his WHOQOL-BREF overall quality of life rating was very good (score: 5; improvement from good to very good); overall health satisfaction rating was good (score: 4; improvement from neither poor nor good to good).
Although the full PE protocol was utilized with Mr. X, interested readers are referred elsewhere
for examples of numerous modifications that can be made to PE without compromising its key elements. For instance, in the case of a patient experiencing severe flashbacks or high levels of emotional distress during imaginal exposure the therapist may tell the patient to keep their eyes open, switch to the past tense in retelling the trauma narrative, and provide grounding comments as the client is retelling the trauma.
Discussion
The older adult population in the United States and other industrialized countries is fast growing, with estimates that older individuals will constitute 20% of the U.S. population over the next 15 years.
This changing demographic will mean an increased need for mental health care for older individuals. Although the majority of older adult trauma survivors do not develop PTSD, a significant minority do. PTSD in older adults is significantly related to psychiatric comorbidities, physical health, and cognitive functioning. If symptoms occur early in life and are left untreated they often wax and wane across the lifespan. EBPs, particularly PE, are safe, acceptable, and appear efficacious in older adults with varied trauma histories and a considerable span of time since traumas. Although two evidence-based psychotherapies, PE and EMDR, have received some empirical investigation in older adults, CPT has received less attention. There is evidence from one randomized controlled trial that older adults may experience better outcomes with exposure as opposed to cognitive therapies. In a study comparing PE and CPT in women with sexual assault–related PTSD, older women who received PE had better outcomes than older women who received CPT, although the reverse was true for younger women.
The authors suggest that this may be due to challenges in changing chronic maladaptive cognitions in older individuals. Caution is warranted, however, as the average participant age in that study was only 32 years and there were relatively few participants aged 55 years and older. This is consistent with one case study on the successful application of PE in a Vietnam veteran with comorbid PTSD and early-stage dementia.
PE was not only associated with significant declines in PTSD symptoms but the patient's cognitive functioning was made clearer with the resolution of severe psychiatric symptoms.
There has been some discussion in the clinical literature that older PTSD patients' level of severity of cognitive impairment may be a key factor in choosing treatment approaches.
It was hypothesized that for older adults with minimal cognitive impairment, the psychotherapies used may be similar to those used in the general adult population: psychoeducation about PTSD, trauma processing, and help with more effective coping with symptoms. Nevertheless, the use of self-management strategies that require retention of new information and implementation of may not be as effective for older adults with PTSD who have moderate to severe declining cognitive abilities.
Importantly, in the systematic review on psychotherapy for PTSD with older adults,
a number of studies indicate that whereas older adults experienced a reduction of PTSD, depression, and anxiety symptoms, few experienced complete remission. Thus, while beneficial, these treatments alone may not be sufficient in older adult populations or the treatments may not have been delivered in a sufficient dose (i.e., intensity and frequency) to produce full benefit.
Most of the PTSD psychotherapy treatment outcome investigations with older adults had non-randomized designs, lacked comparison conditions, had small sample sizes, and did not include full protocols of EBPs. Few studies included follow-up assessments over periods of 6 months or longer. There are few psychotherapy treatment studies on subsets of the older adult population with PTSD, including cultural and ethnic minorities, women, the oldest old (85 + years), and those who are cognitively impaired. The limitations of this research need to be addressed in future studies.
In conclusion, although relatively small, the literature on EBPs for PTSD indicates that PE is safe, acceptable, and efficacious with cognitively intact older adults. Given the aging population growth and its potential impact on mental health practices, it is important to provide older adults access to EBPs for the treatment of PTSD. Healthcare providers are encouraged to add PE as an effective approach to improve clinical care with of their older adult patients with PTSD.
Appendix: Supplementary material
The following is the supplementary data to this article:
in: Sorocco K.H. Lauderdale S. Cognitive Behavior Therapy with Older Adults: Innovations Across Care Settings. Springer Publishing Co,
New York, NY2011: 189-217
Psychiatric comorbidity of full and partial posttraumatic stress disorder among older adults in the United States: results from wave 2 of the national epidemiologic survey on alcohol and related conditions.
Prolonged exposure therapy for older combat veterans in the veterans affairs health care system.
in: Sorocco K.H. Lauderdale S. Cognitive Behavior Therapy with Older Adults: Innovations across Care Settings. Springer Publishing Co,
New York, NY2011: 421-442
Residential treatment for posttraumatic stress disorder in the Department of Veterans Affairs: a national perspective on perceived effective ingredients.
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