Providing Mental Health Care for the Complex Older Veteran: Implications for Social Work Practice

Providing Mental Health Care for the Complex Older Veteran: Implications for Social Work Practice Abstract Mental health conditions are underdiagnosed and undertreated in older veterans, as with all older adults. Social workers bring an important perspective to the interdisciplinary team for the care of older veterans with mental health conditions. In this study authors assessed 50 older veterans referred for mental health treatment (mean age = 74.52 years, SD = 6.48) with standardized measures of depression, posttraumatic stress disorder (PTSD), and cognitive impairment. At initial assessment, 24 percent had moderate depression, 30 percent had PTSD, and 62 percent (n = 31) had (mostly mild) cognitive impairment based on cut scores. These conditions were often comorbid with each other and with social (60 percent), retirement (26 percent), bereavement (32 percent), and financial (36 percent) stressors. Depression improved after three months of treatment [t(30) = 2.12, p = .04], but those with comorbid PTSD or social stressors had more depressive symptoms at follow-up [R2 = .36, F(4, 26) = 3.57, p = .02]. Interdisciplinary care is essential to address the multiple comorbidities and practical complexities of geriatric mental health care. Social workers play a valuable role on the interprofessional team in addressing these complexities. aging, cognition, mental health, posttraumatic stress disorder, veterans The population is aging at astonishing rates. The population age 65 and older increased from 36.2 million in 2004 to 46.2 million in 2014 (a 28 percent increase) and is projected to double to 98 million in 2060 (Administration on Aging [AoA], 2015). The population age 85 and older is projected to triple from 6.2 million in 2014 to 14.6 million in 2040 (AoA, 2015). In this study we focus on mental health treatment of older veterans; one in two men over age 65 are veterans (Federal Interagency Forum on Aging-Related Statistics, 2016). Most older veterans, like most older adults in general, experience good mental health. A portion of older adults experience mental health concerns in late life. These concerns may be mental health problems that started earlier and continued into later life or ones that developed in later life (Institute of Medicine, 2012). As in the care of any person, when social workers provide mental health care to older adults they may view each person from a hierarchy of needs and a person-in-environment (PIE) perspective (Rodwell, 1990). PIE is a strengths-based approach paying particular attention to a person’s ability to function in his or her current environment and the protective factors that presently exist. Interventions may address the formal and informal support system present in the client’s life. The PIE perspective focuses on personal growth and ability to learn, as it applies to the conditions currently facing the individual. For older veterans, a particular condition that may present itself is late life posttraumatic stress disorder (PTSD) (Wisco et al., 2014). Although rates of PTSD are generally low in older adults (Mota et al., 2016), a significant minority of older military veterans have PTSD symptoms related to combat and other traumatic stressors (Wisco et al., 2014). PTSD can persist for years or even decades. Alternatively, symptoms of PTSD may reemerge with stressors of older adulthood (Bottche, Kuwert, & Knaevelsrud, 2012) or developmental processes such as life review (Davison et al., 2016). There is an emerging but still sparse evidence base for the provision of mental health treatment to older adults who have PTSD. Psychotherapy can be effective for this group (Dinnen, Simiola, & Cook, 2015). In addition, psychopharmacology may help with some of the more troubling aspects of PTSD such as sleep disturbances, depressed mood, intrusive thoughts, hyperarousal, and flashbacks (Moye & Rouse, 2014). These symptoms can interfere with activities of daily living and exacerbate chronic medical conditions such as insomnia, diabetes, cardiac disease, and respiratory disease (Burg & Soufer, 2016; Koenen et al., 2016; Lamarche & De Koninck, 2007). Furthermore, older adults with PTSD may have cognitive changes (Schuitevoerder et al., 2013). Cognitive change may set the stage for emergence of PTSD, and PTSD may be a risk factor for the onset of dementia in later life (Yaffe et al., 2010). Although rates of dementia do increase with age, most older adults do not have dementia. Dementia (now termed “major neurocognitive disorder” in DSM-5) consists of a significant cognitive deficit across one or more domains with functional impairment (American Psychiatric Association, 2013). In the clinical setting, dementia is much easier to identify given the more severe nature of cognitive impairments than mild cognitive impairment (MCI) (Ozer, Young, Champ, & Burke, 2016). However, both dementia and MCI will likely complicate mental health treatment for other psychiatric conditions. In this article we describe the characteristics of older adults referred to a general mental health clinic within the Veterans Administration (VA), as well as reports of practitioners of challenges encountered. We use these data as a platform to outline the particular challenges of mental health treatment for complex older adults with interacting psychiatric conditions and the role of the social worker. Method Setting Veterans were recruited from a geriatric mental health clinic with two locations at a multisite Veterans Medical Center. The clinic is designated to focus on provision of treatment for older veterans with general mental health concerns, most often depression. Common but less frequent foci of treatment include adjustment issues—such as adjustment to role changes, medical illness, or the death of a loved one. Veterans with identified PTSD are referred to the specialized PTSD clinic for treatment. However, if we identify PTSD after initiation of care in our general clinic, PTSD treatment is provided in the clinic to ensure continuity of care. The clinic provides psychotherapy, psychopharmacology, and care management in an interdisciplinary context, working closely with each other and other medical providers. Staff come from social work, psychiatry (nursing and MD), and psychology disciplines, with trainees from these disciplines working under the supervision of licensed providers. Participants Veterans were recruited subsequent to referral by a VA provider and standard clinical intake in accordance with an institutional review board–approved research protocol. Over a 16-month period from June 2009 through September 2010, 332 clients were referred to the clinic. Of these, 23 individuals (6.9 percent) were referred to more appropriate clinics (for example, to a substance use treatment program if the primary problem was substance abuse). Of the remaining 309 clients contacted for services, 262 (84.8 percent) completed an initial mental health evaluation in the clinic and 47 declined intake evaluation. After the intake evaluation, clinicians informed clients about the opportunity to participate in this study. Clinicians used judgment about offering participation: If the clinician believed the patient was cognitively impaired (for example, dementia) or psychiatrically unstable (for example, manic, suicidal, delusional), the clinician did not provide study information. Of 262 individuals completing clinical evaluation, 216 (82.4 percent) were considered appropriate for study participation. These veterans were invited to call the research assistant if they had further questions or wanted to schedule an appointment. Of 216 eligible veterans, 110 made contact with the research assistant and 50 (23.1 percent of 216 considered appropriate) consented to participate in the study. Data Sources Within approximately one month of intake evaluation, veterans returned to the clinic to complete baseline standardized measures of depression, PTSD, and cognitive function. At this point, clinicians provided their clinical impressions, including a rating of the individuals’ social and environmental stressors. At three months after initial study assessment, patients were mailed self-report measures of depression to complete and clinicians again provided their impressions, focusing in particular on the challenges in treatment and perceived educational gaps. Thirty-one veterans returned follow-up questionnaires. Participants who completed versus did not complete a three-month follow-up did not differ significantly in terms of age, education, baseline depression, memory impairment, or executive impairment. In addition to questionnaire data, information about the nature and frequency of mental health treatment was extracted from the medical record. Measures Demographics Veterans reported their years of education, race, and date of birth. Depression Depressive symptoms were assessed with the 15-item Geriatric Depression Scale (GDS) (Sheikh & Yesavage, 1986), which has high internal consistency reliability and adequate sensitivity and specificity. A cut score of 8 was used to indicate (moderate) depression. PTSD First, veterans were asked if they had combat experience, defined as “witnessed injured or dying soldiers or experienced shelling or bombardment.” A yes or no response was recorded. For those who answered yes, PTSD symptoms were assessed with the 17-item PTSD Checklist Military version (PCL-M) (Weathers, Litz, Herman, Huska, & Keane, 1993). The PCL-M has good internal consistency reliability and convergent validity, and demonstrates diagnostic sensitivity and specificity. A cut score of 42, which has been suggested for older military veterans (see Cook & O’Donnell, 2005), was used to indicate PTSD. Cognitive Functioning Standardized neuropsychological tests were used to assess specific cognitive domains. Attention and concentration were assessed with the digit span subtest from the Wechsler Adult Intelligence Scale–IV (Wechsler, 2008). Memory was assessed with the California Verbal Learning Test–Second Edition Short Form (Delis, Kramer, Kaplan, & Ober, 2000). Executive functioning was assessed with the Trail Making subtest, Verbal Fluency subtest, and Color-Word Interference subtest of the Delis-Kaplan Executive Functioning System test (Delis, Kaplan, & Kramer, 2001). After computing a standardized score for each subtest based on normative data, a global cut score was determined by averaging the standard scores across subtests. An average cut score of 9 or more was considered within normal limits, with 7 to 8 as mildly impaired, and 6 or less as moderately to severely impaired. Clinician Ratings Clinicians indicated the presence (1) or absence (0) of social distress, rating it present if the veteran reported a decrease, change, or loss of social activities or relationships. Clinicians also rated the presence (1) or absence (0) of four environmental stressors (retirement, bereavement, financial, other). For statistical purposes a cut score was created with 0–1 = no or minimal environmental stress and 2+ = environmental stress. Clinicians also rated responses to the following questions: “Do you feel the patient has improved on the symptoms with which she or he presented?” and “How competent did you feel to meet the patient’s clinical needs to be of help?” on a five-point scale with 0 = not at all, 1 = a little, 2 = some, 3 = a lot, and 4 = completely). Clinicians were also asked, “What were the biggest obstacles or barriers to improvement (patient, system, or clinician)?” Statistical Analyses Demographic and baseline clinical characteristics for the entire sample are summarized with descriptive statistics. Relationships among variables were examined through cross-tabulations and correlation. Change over time was evaluated with paired t test. Predictors of depression after three months of treatment were determined through linear regression. Results Demographic Characteristics Fifty veterans (48 male, 2 female) ages 64 to 88 years (M = 76.8, SD = 7.42) participated in the study. Veterans identified ethnicity as Caucasian or white (n = 44), Hispanic or Latino (n = 3), American Indian (n = 1), African American or black (n = 1), and more than one race (n = 4). Fifty-two percent of veterans had education beyond high school. Clinical Characteristics At initial assessment, 24 percent (n = 12) were depressed based on a GDS moderate cut score; an additional 40 percent (n = 20) had scores indicating mild depressive symptoms. The majority (54 percent, n = 27) stated they had been in combat. Of those, 15 had PTSD; in other words 56 percent of those in combat (15 of 27) had PTSD, or 30 percent of the entire sample (15 of 50). More than half (62 percent, n = 31) had cognitive impairment based on cut scores. Almost all of those with cognitive impairment (29 of 31) had executive or memory impairment only in the mild range. It is noteworthy that all those with moderate depression had either PTSD or cognitive comorbidities (see Figure 1). Figure 1: View largeDownload slide Comorbidities among 38 Participants Notes: Of the remaining 12 in the study sample, eight had mild depression and four had other conditions. PTSD = posttraumatic stress disorder. Figure 1: View largeDownload slide Comorbidities among 38 Participants Notes: Of the remaining 12 in the study sample, eight had mild depression and four had other conditions. PTSD = posttraumatic stress disorder. Environmental stressors were common. Clinicians reported that 60 percent (n = 30) were facing social distress as well as stress related to retirement (26 percent, n = 13), bereavement (32 percent, n = 16), and finances (36 percent, n = 18). Treatment Characteristics Veterans participated in individualized treatment according to their needs and preferences. Seventy-two percent of patients returned to the clinic for at least one psychotherapy visit (range = 1–12, M = 3.90, SD = 3.63), and 62 percent of patients had at least one psychopharmacology visit (range 1–5, M = 1.18, SD = 1.22). Nineteen patients (38 percent) had at least one visit with both a psychiatric provider and a psychotherapist. Only two patients did not return for any mental health services within three months after intake. For those who provided three-month depression scores (n = 31), mean depression scores decreased significantly with treatment, from baseline (M = 6.06, SD = 2.80) to three months later (M = 4.71, SD = 4.00; t(30) = 2.12, p = .04); 19 percent (n = 6) had GDS scores that remained in the depressed range at three months. In multiple linear regression (see Table 1), the total depression score at three months was associated with having PTSD or social distress at baseline [R2 = .36, F(4, 26) = 3.57, p = .02]. Table 1: Prediction of Depression after Three Months of Treatment from Baseline Independent Variable  B  SE  β  t  p  Constant  0.714  1.477    0.483  .63  Cognition  0.276  1.275  .034  0.216  .83  Posttraumatic stress disorder  3.360  1.330  .399  2.526  .02  Social stressors  2.610  1.308  .317  1.995  .05  Environmental stressors  2.445  1.328  .292  1.841  .07  Independent Variable  B  SE  β  t  p  Constant  0.714  1.477    0.483  .63  Cognition  0.276  1.275  .034  0.216  .83  Posttraumatic stress disorder  3.360  1.330  .399  2.526  .02  Social stressors  2.610  1.308  .317  1.995  .05  Environmental stressors  2.445  1.328  .292  1.841  .07  R2 = .36, F(4,26) = 3.57, p = .02. Clinicians reported that they were mostly competent to meet patients’ needs; however, clinicians perceived that patients improved just “a little” (43.2 percent) or “some” (24.3 percent). Perceived patient improvement was significantly related to clinicians’ sense of competence to meet the patients’ needs (r = 0.41, p < .05). The most frequently cited obstacle to treatment was access (for example, travel or payment difficulty, or patient not wanting to come in regularly), in 22 percent (n = 11) of the sample. Patient complexity including cognitive difficulties (20 percent, n = 10) or medical/functional/sleep problems (10 percent, n = 5) were also noted as obstacles. In open-ended responses to “What knowledge or skills do you wish you had to serve this patient even better?” clinicians sought additional information or training regarding health care systems, benefits, and resources; adapting interventions for older adults with PTSD; adapting interventions for older adults with cognitive impairment; working with couples, family, and caregivers; and regarding geriatric medical syndromes. Discussion In this article we describe 50 older veterans presenting to a general mental health clinic. We use these data to describe an interdisciplinary approach to care, with an emphasis on social work practice. Prior to reviewing the results, several limitations are worth noting. We did thorough assessments of the clients at initial presentation but do not have follow-up data for all those enrolled. Our sample size of 50 is small considering the heterogeneity of the overall group, resulting in very small subgroups for analysis. As such, these data should be viewed as descriptive and exploratory, identifying areas for further study. Our clinic is designed to address general mental health concerns in older veterans, particularly depression and adjustment issues. Consistent with this focus, two-thirds of those in this study had depressive symptoms on the GDS in the moderate or mild range. In addition, social, retirement, bereavement, and financial stressors were common. We were intrigued that although the clinic is not a PTSD clinic, about one-third of veterans had PTSD symptoms exceeding a clinical cutoff. In our clinical experience some veterans do not “lead” with their PTSD symptoms when describing distress to referring physicians, or even once in a mental health clinic, but instead open up about those symptoms with gentle probing and education. For some, cognitive changes or late-life transitions may bring PTSD symptoms to the surface (Davison et al., 2016). In addition, we were surprised that although we ruled out those with dementia, almost two-thirds had some degree of cognitive impairment, although mostly in the mild range. Despite these challenges, overall the group improved within just three months on a measure of depression. This is consistent with the general literature that treatment for depression is effective for older adults (Apostolo, Queiros, Rodrigues, Castro, & Cardoso, 2015), as well as a more general strengths-based approach to care that emphasizes the potential for positive change. Nevertheless, challenges in this population point to the importance of both the social worker and the interdisciplinary team. Veterans with comorbid PTSD and social stressors had higher depression scores at three months, consistent with another study (Chan, Fan, & Unützer, 2011). In addition, practical issues with access were thought to impede care. Clinicians identified training about resources as something that would assist them in serving this population. Consideration of the social and environmental context may be natural to social workers and is something they can teach colleagues from other disciplines. Working with veterans to identify their support systems, both formal and informal, can add support and structure to assist with positive outcomes. When impediments are discussed and resolved through positive involvement of family and other informal supports, veterans are typically able to continue treatment and work more effectively toward recovery. Furthermore, clinicians described complicating medical, functional, and sleep problems and their need for knowledge of geriatric medical syndromes as factors impeding care. These findings support the importance of working with medically oriented colleagues who can understand the role of these comorbidities in the mental health treatment and, where appropriate, offer pharmacologic treatment for distressing symptoms. Pharmacologic interventions usually target the core symptoms of depression and PTSD including sleep disturbance, depressed mood, hyperarousal, and re-experiencing with focus on restoring balance to the natural inhibitory response in the brain. As with all psychiatric medications used in older adults, the focus is on treating distressing symptoms but minimizing adverse side effects. In our team, geriatric-trained psychiatric nurses and psychiatrists accomplish this by adhering to cautious titration, which improves tolerance and confidence in the patient, thus improving compliance. This allows the prescriber to reach a therapeutic dose of medication, increasing rates of symptom improvement. The social worker can play a valuable role in collaborating with psychiatric providers and supporting the client through this sometimes time consuming but important process of finding the most helpful medication and dosage. Education related to medications, symptom monitoring, and compliance monitoring in the older patient is dependent on a comprehensive team approach. Each member of the team can monitor for subtle changes in symptoms and ensuring that the client is tolerating treatment with regard to safety and symptom improvement. Practical Recommendations Address Access and Environmental Barriers In this study, travel was a barrier to older veterans seeking mental health treatment. With that specific knowledge, on initial telephone contact with older veterans travel options and barriers should be discussed and resources provided. A follow-up telephone call confirming transportation and reminding of the appointment is helpful as well as simply inquiring if the veteran is recording the appointment on a calendar. In addition, when available, telehealth can be used to complement or substitute for in-person visits. Clinicians identified lack of knowledge of resources as a barrier. Social workers can bring their expertise in resource identification to the care of the patient and their interdisciplinary colleagues. Decrease Stigma Incorporating these environmental factors, consideration may be taken to identify motivation to change and the client’s desire to seek treatment for depression, anxiety, PTSD, or whatever emerges as the key mental health concerns. In our experience, older veterans’ view on psychotherapy is often through the lens of shame and guilt, not wanting family or friends to know that they are seeking help. When impediments are discussed and resolved, veterans are typically supported and encouraged by family to continue treatment and enter a phase of recovery. Screen for Cognitive Problems When Indicated Cognitive problems—although mild—were common in this client sample and perhaps not notable on clinical interview. It is therefore important to be alert to potential cognitive concerns. An older adult may verbalize memory concerns they have or that their family has told them, such as losing items, missing bill payments, or getting lost in familiar areas. After a brief cognitive screen (two options available online are the Montreal Cognitive Assessment [http://www.mocatest.org] and the St. Louis University Mental Status Exam [http://aging.slu.edu/index.php?page=saint-louis-university-mental-status-slums-exam]), the client can be referred for further testing if indicated (Lin, O’Connor, Rossom, Perdue, & Eckstrom, 2013). The main focus would be on ability to safely live at home and to collaborate with the neuropsychologists administering the test. In addition to identifying potential problems, neuropsychological testing can be used to develop recommendations for interventions. This comprehensive approach benefits veterans in understanding the changes in the brain, allowing them to focus on their cognitive strengths and adapt to difficulties. Consider PTSD In addition to screening for cognitive impairments, it is also important to screen for PTSD. Oftentimes the veterans we treat have limited education or understanding regarding the role of military trauma in their life. In our experience education alone about PTSD can have a tremendous positive treatment effect in explaining the life course—for example when veterans are isolated from family or have had multiple failed relationships related to PTSD, they may feel less stigma. Discussing the role of PTSD in relationships provides a relief to veterans as they are able to openly discuss their psychosocial history as it relates to their military trauma. As the data indicate, comorbid PTSD can be a risk factor for lack of recovery or even worsening distress over the course of mental health treatment, but veterans may not identify PTSD as the reason for needing help. These factors suggest that the social worker and entire health care team need to approach these issues in an informed and gentle manner. There are a number of well-established assessment tools for PTSD (see http://www.ptsd.va.gov, for more information). In addition to providing clinical information, the assessment can elicit thoughtful responses from the veteran and an opportunity to provide education. Similar to that of depression, treatment for PTSD can be effective in older adults. Conclusion Older adults who present for mental health treatment can be particularly complex on the person and environment level, but nevertheless improve. Interdisciplinary care is essential to address the multiple comorbidities and practical complexities of geriatric mental health care. Social workers play a valuable role on the interprofessional team in addressing mental health concerns of the PIE context. References Administration on Aging. ( 2015). A profile of older Americans: 2015 . Washington, DC: U.S. Department of Health and Human Services. American Psychiatric Association. ( 2013). Diagnostic and statistical manual of mental disorders  ( 5th ed.). Washington, DC: Author. Apostolo, J., Queiros, P., Rodrigues, M., Castro, I., & Cardoso, D. ( 2015). The effectiveness of nonpharmacological interventions in older adults with depressive disorders: A systematic review. JBI Database of Systematic Reviews and Implementation Reports,  13( 6), 220– 278. doi:10.11124/jbisrir-2015-1718 Bottche, M., Kuwert, P., & Knaevelsrud, C. ( 2012). Posttraumatic stress disorder in older adults: An overview of characteristics and treatment approaches. International Journal of Geriatric Psychiatry,  27( 3), 230– 239. doi:10.1002/gps.2725 Google Scholar CrossRef Search ADS   Burg, M. M., & Soufer, R. ( 2016). Post-traumatic stress disorder and cardiovascular disease. Current Cardiology Reports,  18( 10), 94– 101. doi:10.1007/s11886-016-0770-5 Google Scholar CrossRef Search ADS   Chan, D., Fan, M., & Unützer, J. ( 2011). Long-term effectiveness of collaborative depression care in older primary care patients with and without PTSD symptoms. International Journal of Geriatric Psychiatry,  26, 758– 764. doi:10.1002/gps.2606 Google Scholar CrossRef Search ADS   Cook, J. M., & O’Donnell, C. ( 2005). Assessment and psychological treatment of posttraumatic stress disorder in older adults. Journal of Geriatric Psychiatry & Neurology,  18( 2), 61– 71. doi:10.1177/0891988705276052 Google Scholar CrossRef Search ADS   Davison, E. H., Kaiser, A. P., Spiro, A., Moye, J., King, L. A., & King, D. W. ( 2016). Later adulthood trauma reengagement (LATR) among aging combat veterans. Gerontologist,  56, 14– 21. doi:10.1093/geront/gnv097 Google Scholar CrossRef Search ADS   Delis, D. C., Kaplan, E., & Kramer, J. H. ( 2001). Delis-Kaplan Executive Function System (D-KEFS).  San Antonio, TX: Pearson. Delis, D. C., Kramer, J. H., Kaplan, E., & Ober, B. A. ( 2000). California Verbal Learning Test  ( 2nd ed.). San Antonio, TX: Pearson. Dinnen, S., Simiola, V., & Cook, J. M. ( 2015). Post-traumatic stress disorder in older adults: A systematic review of the psychotherapy treatment literature. Aging & Mental Health,  19( 2), 144– 150. doi:10.1080/13607863.2014.920299 Google Scholar CrossRef Search ADS   Federal Interagency Forum on Aging-Related Statistics. ( 2016). Older Americans 2016: Key indicators of well-being.  Washington, DC: U.S. Government Printing Office. Institute of Medicine. ( 2012). The mental health and substance use workforce for older adults: In whose hands?  Washington, DC: National Academies Press. Koenen, K. C., Sumner, J. A., Gilsanz, P., Glymour, M. M., Ratanatharathorn, A., Rimm, E. B., et al.  . ( 2016). Post-traumatic stress disorder and cardiometabolic disease: Improving causal inference to inform practice. Psychological Medicine,  4, 1– 17. doi:10.1017/S0033291716002294 Lamarche, L. J., & De Koninck, J. ( 2007). Sleep disturbance in adults with posttraumatic stress disorder: A review. Journal of Clinical Psychiatry,  68, 1257– 1270. Google Scholar CrossRef Search ADS   Lin, J. S., O’Connor, E., Rossom, R. C., Perdue, L. A., & Eckstrom, E. ( 2013). Screening for cognitive impairment in older adults: A systematic review for the U.S. Preventive Services Task Force. Annals of Internal Medicine,  159, 601– 612. doi:10.7326/0003-4819-159-9-201311050-00730 Mota, N., Tsai, J., Kirwin, P. D., Harpaz-Rotem, I., Krystal, J. H., Southwick, S. M., & Pietrzak, R. H. ( 2016). Late-life exacerbation of PTSD symptoms in US veterans: Results from the national health and resilience in veterans study. Journal of Clinical Psychiatry,  77, 348– 354. doi:10.4088/JCP.15m10101 Google Scholar CrossRef Search ADS   Moye, J., & Rouse, S. J. ( 2014). Posttraumatic stress in older adults: When medical diagnoses or treatments cause traumatic stress. Clinics in Geriatric Medicine,  30, 577– 589. doi:10.1016/j.cger.2014.04.006 Google Scholar CrossRef Search ADS   Ozer, S., Young, J., Champ, C., & Burke, M. ( 2016). A systematic review of the diagnostic test accuracy of brief cognitive tests to detect amnestic mild cognitive impairment. International Journal of Geriatric Psychiatry,  31, 1139– 1150 doi:10.1002/gps.4444 Google Scholar CrossRef Search ADS   Rodwell, M. K. ( 1990). Person/environment construct: Positivist versus naturalist, dilemma or opportunity for health social work research and practice? Social Science and Medicine,  31( 1), 27– 34. Google Scholar CrossRef Search ADS   Schuitevoerder, S., Rosen, J. W., Twamley, E. W., Ayers, C. R., Sones, H., Lohr, J. B., et al.  . ( 2013). A meta-analysis of cognitive functioning in older adults with PTSD. Journal of Anxiety Disorders,  27, 550– 558. doi:10.1016/j.janxdis.2013.01.001 Google Scholar CrossRef Search ADS   Sheikh, J. I., & Yesavage, J. A. ( 1986). Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist,  5, 165– 173. Google Scholar CrossRef Search ADS   Weathers, F. W., Litz, B. T., Herman, D. S., Huska, J. A., & Keane, T. M. ( 1993, October). The PTSD Checklist (PCL-C): Reliability, validity, and diagnostic utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX. Wechsler, D. ( 2008). Wechsler Adult Intelligence Scale  ( 4th ed.). San Antonio, TX: Psychological Corporation. Wisco, B. E., Marx, B. P., Wolf, E. J., Miller, M. W., Southwick, S. M., & Pietrzak, R. H. ( 2014). Posttraumatic stress disorder in the US veteran population: Results from the National Health and Resilience in Veterans Study. Journal of Clinical Psychiatry,  75, 1338– 1346. doi:10.4088/JCP.14m09328 Google Scholar CrossRef Search ADS   Yaffe, K., Vittinghoff, E., Lindquist, K., Barnes, D., Covinsky, K. E., Neylan, T., et al.  . ( 2010). Posttraumatic stress disorder and risk of dementia among US veterans. Archives of General Psychiatry,  67, 608– 613. doi:10.1001/archgenpsychiatry.2010.61 Google Scholar CrossRef Search ADS   Author notes This material is the result of work supported with resources and the use of facilities at the Boston VA Medical Center and the Boston VA Research Institute. Additional support for the study was provided by the National Center for PTSD through the Stress, Health, and Aging Research Program (SHARP). The authors thank the Geriatric Mental Health Clinic staff and trainees as well as SHARP investigators for their input. The authors are indebted to the many veterans who have allowed them to participate in their care and who contributed to this study. © 2017 National Association of Social Workers http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health & Social Work Oxford University Press

Providing Mental Health Care for the Complex Older Veteran: Implications for Social Work Practice

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Abstract

Abstract Mental health conditions are underdiagnosed and undertreated in older veterans, as with all older adults. Social workers bring an important perspective to the interdisciplinary team for the care of older veterans with mental health conditions. In this study authors assessed 50 older veterans referred for mental health treatment (mean age = 74.52 years, SD = 6.48) with standardized measures of depression, posttraumatic stress disorder (PTSD), and cognitive impairment. At initial assessment, 24 percent had moderate depression, 30 percent had PTSD, and 62 percent (n = 31) had (mostly mild) cognitive impairment based on cut scores. These conditions were often comorbid with each other and with social (60 percent), retirement (26 percent), bereavement (32 percent), and financial (36 percent) stressors. Depression improved after three months of treatment [t(30) = 2.12, p = .04], but those with comorbid PTSD or social stressors had more depressive symptoms at follow-up [R2 = .36, F(4, 26) = 3.57, p = .02]. Interdisciplinary care is essential to address the multiple comorbidities and practical complexities of geriatric mental health care. Social workers play a valuable role on the interprofessional team in addressing these complexities. aging, cognition, mental health, posttraumatic stress disorder, veterans The population is aging at astonishing rates. The population age 65 and older increased from 36.2 million in 2004 to 46.2 million in 2014 (a 28 percent increase) and is projected to double to 98 million in 2060 (Administration on Aging [AoA], 2015). The population age 85 and older is projected to triple from 6.2 million in 2014 to 14.6 million in 2040 (AoA, 2015). In this study we focus on mental health treatment of older veterans; one in two men over age 65 are veterans (Federal Interagency Forum on Aging-Related Statistics, 2016). Most older veterans, like most older adults in general, experience good mental health. A portion of older adults experience mental health concerns in late life. These concerns may be mental health problems that started earlier and continued into later life or ones that developed in later life (Institute of Medicine, 2012). As in the care of any person, when social workers provide mental health care to older adults they may view each person from a hierarchy of needs and a person-in-environment (PIE) perspective (Rodwell, 1990). PIE is a strengths-based approach paying particular attention to a person’s ability to function in his or her current environment and the protective factors that presently exist. Interventions may address the formal and informal support system present in the client’s life. The PIE perspective focuses on personal growth and ability to learn, as it applies to the conditions currently facing the individual. For older veterans, a particular condition that may present itself is late life posttraumatic stress disorder (PTSD) (Wisco et al., 2014). Although rates of PTSD are generally low in older adults (Mota et al., 2016), a significant minority of older military veterans have PTSD symptoms related to combat and other traumatic stressors (Wisco et al., 2014). PTSD can persist for years or even decades. Alternatively, symptoms of PTSD may reemerge with stressors of older adulthood (Bottche, Kuwert, & Knaevelsrud, 2012) or developmental processes such as life review (Davison et al., 2016). There is an emerging but still sparse evidence base for the provision of mental health treatment to older adults who have PTSD. Psychotherapy can be effective for this group (Dinnen, Simiola, & Cook, 2015). In addition, psychopharmacology may help with some of the more troubling aspects of PTSD such as sleep disturbances, depressed mood, intrusive thoughts, hyperarousal, and flashbacks (Moye & Rouse, 2014). These symptoms can interfere with activities of daily living and exacerbate chronic medical conditions such as insomnia, diabetes, cardiac disease, and respiratory disease (Burg & Soufer, 2016; Koenen et al., 2016; Lamarche & De Koninck, 2007). Furthermore, older adults with PTSD may have cognitive changes (Schuitevoerder et al., 2013). Cognitive change may set the stage for emergence of PTSD, and PTSD may be a risk factor for the onset of dementia in later life (Yaffe et al., 2010). Although rates of dementia do increase with age, most older adults do not have dementia. Dementia (now termed “major neurocognitive disorder” in DSM-5) consists of a significant cognitive deficit across one or more domains with functional impairment (American Psychiatric Association, 2013). In the clinical setting, dementia is much easier to identify given the more severe nature of cognitive impairments than mild cognitive impairment (MCI) (Ozer, Young, Champ, & Burke, 2016). However, both dementia and MCI will likely complicate mental health treatment for other psychiatric conditions. In this article we describe the characteristics of older adults referred to a general mental health clinic within the Veterans Administration (VA), as well as reports of practitioners of challenges encountered. We use these data as a platform to outline the particular challenges of mental health treatment for complex older adults with interacting psychiatric conditions and the role of the social worker. Method Setting Veterans were recruited from a geriatric mental health clinic with two locations at a multisite Veterans Medical Center. The clinic is designated to focus on provision of treatment for older veterans with general mental health concerns, most often depression. Common but less frequent foci of treatment include adjustment issues—such as adjustment to role changes, medical illness, or the death of a loved one. Veterans with identified PTSD are referred to the specialized PTSD clinic for treatment. However, if we identify PTSD after initiation of care in our general clinic, PTSD treatment is provided in the clinic to ensure continuity of care. The clinic provides psychotherapy, psychopharmacology, and care management in an interdisciplinary context, working closely with each other and other medical providers. Staff come from social work, psychiatry (nursing and MD), and psychology disciplines, with trainees from these disciplines working under the supervision of licensed providers. Participants Veterans were recruited subsequent to referral by a VA provider and standard clinical intake in accordance with an institutional review board–approved research protocol. Over a 16-month period from June 2009 through September 2010, 332 clients were referred to the clinic. Of these, 23 individuals (6.9 percent) were referred to more appropriate clinics (for example, to a substance use treatment program if the primary problem was substance abuse). Of the remaining 309 clients contacted for services, 262 (84.8 percent) completed an initial mental health evaluation in the clinic and 47 declined intake evaluation. After the intake evaluation, clinicians informed clients about the opportunity to participate in this study. Clinicians used judgment about offering participation: If the clinician believed the patient was cognitively impaired (for example, dementia) or psychiatrically unstable (for example, manic, suicidal, delusional), the clinician did not provide study information. Of 262 individuals completing clinical evaluation, 216 (82.4 percent) were considered appropriate for study participation. These veterans were invited to call the research assistant if they had further questions or wanted to schedule an appointment. Of 216 eligible veterans, 110 made contact with the research assistant and 50 (23.1 percent of 216 considered appropriate) consented to participate in the study. Data Sources Within approximately one month of intake evaluation, veterans returned to the clinic to complete baseline standardized measures of depression, PTSD, and cognitive function. At this point, clinicians provided their clinical impressions, including a rating of the individuals’ social and environmental stressors. At three months after initial study assessment, patients were mailed self-report measures of depression to complete and clinicians again provided their impressions, focusing in particular on the challenges in treatment and perceived educational gaps. Thirty-one veterans returned follow-up questionnaires. Participants who completed versus did not complete a three-month follow-up did not differ significantly in terms of age, education, baseline depression, memory impairment, or executive impairment. In addition to questionnaire data, information about the nature and frequency of mental health treatment was extracted from the medical record. Measures Demographics Veterans reported their years of education, race, and date of birth. Depression Depressive symptoms were assessed with the 15-item Geriatric Depression Scale (GDS) (Sheikh & Yesavage, 1986), which has high internal consistency reliability and adequate sensitivity and specificity. A cut score of 8 was used to indicate (moderate) depression. PTSD First, veterans were asked if they had combat experience, defined as “witnessed injured or dying soldiers or experienced shelling or bombardment.” A yes or no response was recorded. For those who answered yes, PTSD symptoms were assessed with the 17-item PTSD Checklist Military version (PCL-M) (Weathers, Litz, Herman, Huska, & Keane, 1993). The PCL-M has good internal consistency reliability and convergent validity, and demonstrates diagnostic sensitivity and specificity. A cut score of 42, which has been suggested for older military veterans (see Cook & O’Donnell, 2005), was used to indicate PTSD. Cognitive Functioning Standardized neuropsychological tests were used to assess specific cognitive domains. Attention and concentration were assessed with the digit span subtest from the Wechsler Adult Intelligence Scale–IV (Wechsler, 2008). Memory was assessed with the California Verbal Learning Test–Second Edition Short Form (Delis, Kramer, Kaplan, & Ober, 2000). Executive functioning was assessed with the Trail Making subtest, Verbal Fluency subtest, and Color-Word Interference subtest of the Delis-Kaplan Executive Functioning System test (Delis, Kaplan, & Kramer, 2001). After computing a standardized score for each subtest based on normative data, a global cut score was determined by averaging the standard scores across subtests. An average cut score of 9 or more was considered within normal limits, with 7 to 8 as mildly impaired, and 6 or less as moderately to severely impaired. Clinician Ratings Clinicians indicated the presence (1) or absence (0) of social distress, rating it present if the veteran reported a decrease, change, or loss of social activities or relationships. Clinicians also rated the presence (1) or absence (0) of four environmental stressors (retirement, bereavement, financial, other). For statistical purposes a cut score was created with 0–1 = no or minimal environmental stress and 2+ = environmental stress. Clinicians also rated responses to the following questions: “Do you feel the patient has improved on the symptoms with which she or he presented?” and “How competent did you feel to meet the patient’s clinical needs to be of help?” on a five-point scale with 0 = not at all, 1 = a little, 2 = some, 3 = a lot, and 4 = completely). Clinicians were also asked, “What were the biggest obstacles or barriers to improvement (patient, system, or clinician)?” Statistical Analyses Demographic and baseline clinical characteristics for the entire sample are summarized with descriptive statistics. Relationships among variables were examined through cross-tabulations and correlation. Change over time was evaluated with paired t test. Predictors of depression after three months of treatment were determined through linear regression. Results Demographic Characteristics Fifty veterans (48 male, 2 female) ages 64 to 88 years (M = 76.8, SD = 7.42) participated in the study. Veterans identified ethnicity as Caucasian or white (n = 44), Hispanic or Latino (n = 3), American Indian (n = 1), African American or black (n = 1), and more than one race (n = 4). Fifty-two percent of veterans had education beyond high school. Clinical Characteristics At initial assessment, 24 percent (n = 12) were depressed based on a GDS moderate cut score; an additional 40 percent (n = 20) had scores indicating mild depressive symptoms. The majority (54 percent, n = 27) stated they had been in combat. Of those, 15 had PTSD; in other words 56 percent of those in combat (15 of 27) had PTSD, or 30 percent of the entire sample (15 of 50). More than half (62 percent, n = 31) had cognitive impairment based on cut scores. Almost all of those with cognitive impairment (29 of 31) had executive or memory impairment only in the mild range. It is noteworthy that all those with moderate depression had either PTSD or cognitive comorbidities (see Figure 1). Figure 1: View largeDownload slide Comorbidities among 38 Participants Notes: Of the remaining 12 in the study sample, eight had mild depression and four had other conditions. PTSD = posttraumatic stress disorder. Figure 1: View largeDownload slide Comorbidities among 38 Participants Notes: Of the remaining 12 in the study sample, eight had mild depression and four had other conditions. PTSD = posttraumatic stress disorder. Environmental stressors were common. Clinicians reported that 60 percent (n = 30) were facing social distress as well as stress related to retirement (26 percent, n = 13), bereavement (32 percent, n = 16), and finances (36 percent, n = 18). Treatment Characteristics Veterans participated in individualized treatment according to their needs and preferences. Seventy-two percent of patients returned to the clinic for at least one psychotherapy visit (range = 1–12, M = 3.90, SD = 3.63), and 62 percent of patients had at least one psychopharmacology visit (range 1–5, M = 1.18, SD = 1.22). Nineteen patients (38 percent) had at least one visit with both a psychiatric provider and a psychotherapist. Only two patients did not return for any mental health services within three months after intake. For those who provided three-month depression scores (n = 31), mean depression scores decreased significantly with treatment, from baseline (M = 6.06, SD = 2.80) to three months later (M = 4.71, SD = 4.00; t(30) = 2.12, p = .04); 19 percent (n = 6) had GDS scores that remained in the depressed range at three months. In multiple linear regression (see Table 1), the total depression score at three months was associated with having PTSD or social distress at baseline [R2 = .36, F(4, 26) = 3.57, p = .02]. Table 1: Prediction of Depression after Three Months of Treatment from Baseline Independent Variable  B  SE  β  t  p  Constant  0.714  1.477    0.483  .63  Cognition  0.276  1.275  .034  0.216  .83  Posttraumatic stress disorder  3.360  1.330  .399  2.526  .02  Social stressors  2.610  1.308  .317  1.995  .05  Environmental stressors  2.445  1.328  .292  1.841  .07  Independent Variable  B  SE  β  t  p  Constant  0.714  1.477    0.483  .63  Cognition  0.276  1.275  .034  0.216  .83  Posttraumatic stress disorder  3.360  1.330  .399  2.526  .02  Social stressors  2.610  1.308  .317  1.995  .05  Environmental stressors  2.445  1.328  .292  1.841  .07  R2 = .36, F(4,26) = 3.57, p = .02. Clinicians reported that they were mostly competent to meet patients’ needs; however, clinicians perceived that patients improved just “a little” (43.2 percent) or “some” (24.3 percent). Perceived patient improvement was significantly related to clinicians’ sense of competence to meet the patients’ needs (r = 0.41, p < .05). The most frequently cited obstacle to treatment was access (for example, travel or payment difficulty, or patient not wanting to come in regularly), in 22 percent (n = 11) of the sample. Patient complexity including cognitive difficulties (20 percent, n = 10) or medical/functional/sleep problems (10 percent, n = 5) were also noted as obstacles. In open-ended responses to “What knowledge or skills do you wish you had to serve this patient even better?” clinicians sought additional information or training regarding health care systems, benefits, and resources; adapting interventions for older adults with PTSD; adapting interventions for older adults with cognitive impairment; working with couples, family, and caregivers; and regarding geriatric medical syndromes. Discussion In this article we describe 50 older veterans presenting to a general mental health clinic. We use these data to describe an interdisciplinary approach to care, with an emphasis on social work practice. Prior to reviewing the results, several limitations are worth noting. We did thorough assessments of the clients at initial presentation but do not have follow-up data for all those enrolled. Our sample size of 50 is small considering the heterogeneity of the overall group, resulting in very small subgroups for analysis. As such, these data should be viewed as descriptive and exploratory, identifying areas for further study. Our clinic is designed to address general mental health concerns in older veterans, particularly depression and adjustment issues. Consistent with this focus, two-thirds of those in this study had depressive symptoms on the GDS in the moderate or mild range. In addition, social, retirement, bereavement, and financial stressors were common. We were intrigued that although the clinic is not a PTSD clinic, about one-third of veterans had PTSD symptoms exceeding a clinical cutoff. In our clinical experience some veterans do not “lead” with their PTSD symptoms when describing distress to referring physicians, or even once in a mental health clinic, but instead open up about those symptoms with gentle probing and education. For some, cognitive changes or late-life transitions may bring PTSD symptoms to the surface (Davison et al., 2016). In addition, we were surprised that although we ruled out those with dementia, almost two-thirds had some degree of cognitive impairment, although mostly in the mild range. Despite these challenges, overall the group improved within just three months on a measure of depression. This is consistent with the general literature that treatment for depression is effective for older adults (Apostolo, Queiros, Rodrigues, Castro, & Cardoso, 2015), as well as a more general strengths-based approach to care that emphasizes the potential for positive change. Nevertheless, challenges in this population point to the importance of both the social worker and the interdisciplinary team. Veterans with comorbid PTSD and social stressors had higher depression scores at three months, consistent with another study (Chan, Fan, & Unützer, 2011). In addition, practical issues with access were thought to impede care. Clinicians identified training about resources as something that would assist them in serving this population. Consideration of the social and environmental context may be natural to social workers and is something they can teach colleagues from other disciplines. Working with veterans to identify their support systems, both formal and informal, can add support and structure to assist with positive outcomes. When impediments are discussed and resolved through positive involvement of family and other informal supports, veterans are typically able to continue treatment and work more effectively toward recovery. Furthermore, clinicians described complicating medical, functional, and sleep problems and their need for knowledge of geriatric medical syndromes as factors impeding care. These findings support the importance of working with medically oriented colleagues who can understand the role of these comorbidities in the mental health treatment and, where appropriate, offer pharmacologic treatment for distressing symptoms. Pharmacologic interventions usually target the core symptoms of depression and PTSD including sleep disturbance, depressed mood, hyperarousal, and re-experiencing with focus on restoring balance to the natural inhibitory response in the brain. As with all psychiatric medications used in older adults, the focus is on treating distressing symptoms but minimizing adverse side effects. In our team, geriatric-trained psychiatric nurses and psychiatrists accomplish this by adhering to cautious titration, which improves tolerance and confidence in the patient, thus improving compliance. This allows the prescriber to reach a therapeutic dose of medication, increasing rates of symptom improvement. The social worker can play a valuable role in collaborating with psychiatric providers and supporting the client through this sometimes time consuming but important process of finding the most helpful medication and dosage. Education related to medications, symptom monitoring, and compliance monitoring in the older patient is dependent on a comprehensive team approach. Each member of the team can monitor for subtle changes in symptoms and ensuring that the client is tolerating treatment with regard to safety and symptom improvement. Practical Recommendations Address Access and Environmental Barriers In this study, travel was a barrier to older veterans seeking mental health treatment. With that specific knowledge, on initial telephone contact with older veterans travel options and barriers should be discussed and resources provided. A follow-up telephone call confirming transportation and reminding of the appointment is helpful as well as simply inquiring if the veteran is recording the appointment on a calendar. In addition, when available, telehealth can be used to complement or substitute for in-person visits. Clinicians identified lack of knowledge of resources as a barrier. Social workers can bring their expertise in resource identification to the care of the patient and their interdisciplinary colleagues. Decrease Stigma Incorporating these environmental factors, consideration may be taken to identify motivation to change and the client’s desire to seek treatment for depression, anxiety, PTSD, or whatever emerges as the key mental health concerns. In our experience, older veterans’ view on psychotherapy is often through the lens of shame and guilt, not wanting family or friends to know that they are seeking help. When impediments are discussed and resolved, veterans are typically supported and encouraged by family to continue treatment and enter a phase of recovery. Screen for Cognitive Problems When Indicated Cognitive problems—although mild—were common in this client sample and perhaps not notable on clinical interview. It is therefore important to be alert to potential cognitive concerns. An older adult may verbalize memory concerns they have or that their family has told them, such as losing items, missing bill payments, or getting lost in familiar areas. After a brief cognitive screen (two options available online are the Montreal Cognitive Assessment [http://www.mocatest.org] and the St. Louis University Mental Status Exam [http://aging.slu.edu/index.php?page=saint-louis-university-mental-status-slums-exam]), the client can be referred for further testing if indicated (Lin, O’Connor, Rossom, Perdue, & Eckstrom, 2013). The main focus would be on ability to safely live at home and to collaborate with the neuropsychologists administering the test. In addition to identifying potential problems, neuropsychological testing can be used to develop recommendations for interventions. This comprehensive approach benefits veterans in understanding the changes in the brain, allowing them to focus on their cognitive strengths and adapt to difficulties. Consider PTSD In addition to screening for cognitive impairments, it is also important to screen for PTSD. Oftentimes the veterans we treat have limited education or understanding regarding the role of military trauma in their life. In our experience education alone about PTSD can have a tremendous positive treatment effect in explaining the life course—for example when veterans are isolated from family or have had multiple failed relationships related to PTSD, they may feel less stigma. Discussing the role of PTSD in relationships provides a relief to veterans as they are able to openly discuss their psychosocial history as it relates to their military trauma. As the data indicate, comorbid PTSD can be a risk factor for lack of recovery or even worsening distress over the course of mental health treatment, but veterans may not identify PTSD as the reason for needing help. These factors suggest that the social worker and entire health care team need to approach these issues in an informed and gentle manner. There are a number of well-established assessment tools for PTSD (see http://www.ptsd.va.gov, for more information). In addition to providing clinical information, the assessment can elicit thoughtful responses from the veteran and an opportunity to provide education. Similar to that of depression, treatment for PTSD can be effective in older adults. Conclusion Older adults who present for mental health treatment can be particularly complex on the person and environment level, but nevertheless improve. Interdisciplinary care is essential to address the multiple comorbidities and practical complexities of geriatric mental health care. Social workers play a valuable role on the interprofessional team in addressing mental health concerns of the PIE context. References Administration on Aging. ( 2015). A profile of older Americans: 2015 . 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Posttraumatic stress disorder in the US veteran population: Results from the National Health and Resilience in Veterans Study. Journal of Clinical Psychiatry,  75, 1338– 1346. doi:10.4088/JCP.14m09328 Google Scholar CrossRef Search ADS   Yaffe, K., Vittinghoff, E., Lindquist, K., Barnes, D., Covinsky, K. E., Neylan, T., et al.  . ( 2010). Posttraumatic stress disorder and risk of dementia among US veterans. Archives of General Psychiatry,  67, 608– 613. doi:10.1001/archgenpsychiatry.2010.61 Google Scholar CrossRef Search ADS   Author notes This material is the result of work supported with resources and the use of facilities at the Boston VA Medical Center and the Boston VA Research Institute. Additional support for the study was provided by the National Center for PTSD through the Stress, Health, and Aging Research Program (SHARP). The authors thank the Geriatric Mental Health Clinic staff and trainees as well as SHARP investigators for their input. The authors are indebted to the many veterans who have allowed them to participate in their care and who contributed to this study. © 2017 National Association of Social Workers

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Health & Social WorkOxford University Press

Published: Feb 1, 2018

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