RED DE SANEAMIENTO Pluviales 1 DEFINICIÓN

1.3.1 Late-Life Reactions to Trauma

While some research indicates that declining psychological and social resources during later life inhibits effective coping and creates susceptibility to traumatic stress, other research suggests that older people are more resilient to the effects of stress and trauma due to increased life experiences ( Solomon & Ginzburg, 1998). As will be discussed, the fact that age has been implicated as both a risk factor ( e.g., Livingston, Livingston, Brooks & McKinley, 1992) and a protective factor ( e.g., Clipp & Elder, 1996) in the development of PTSD depicts the value of further research regarding trauma-related symptoms and aging.

The vulnerability perspective of aging to stress and trauma was originally accepted as being self-explanatory and quite plausible. The argument was that older people suffer from physical, cognitive and social decline, therefore, psychological resources for dealing with stress must also be depleted. However, older people frequently use a strategy called selective optimization by compensation ( SOC), by adjusting expectations and reducing the number of areas in their lives to be managed ( Baltes & Baltes, 1990). Otherwise defined as proactive coping ( Ouwehand, deRidder, & Bensing, 2007), SOC is considered crucial for successful aging as it involves active efforts at preventing potential threats to selected objectives and compensatory processes to make up for deficiencies or losses. For example, declines in health and physical ability can threaten the goal for

8

TRAUMA AND THE ELDERLY

independent functioning and autonomy, influencing quality of life and psychological well­ being. By using available physical and material resources to facilitate independent living within the most important areas of concern (e.g., living in one's own home; personal care activities), while accepting assistance in other areas (e.g., shopping), one can maintain life-quality and prevent psychological decline.

Supporting the resiliency perspective of aging and trauma are reviews of research (see Summers & Hyer, 1 994) on the psychological effects of a series of natural disasters that have identified older people as reporting the lowest levels of depression (Gatz, 1 999, as cited in Hyer & Sohnle, 200 1 ; Havens, 1 999, as cited in Hyer & Sohnle, 200 1 ), PTSD (Bolin & Klenow, 1 982) and anxiety (Bell, 1 978), when compared with younger age­ groups. Studies of acute posttraumatic reactions to natural disasters have also identified older adults as experiencing the lowest levels of anxiety, fear, worry, psychological distress and alcohol consumption, superior recovery and higher levels of positive affect, as compared to younger adults (Bell, 1 978; Huerta & Horton, 1 978).

Further scrutiny of the trauma literature, however, uncovers findings that challenge the resiliency perspective of aging and trauma. A study of survivors of the Lockerbie air disaster, for example, portrayed that although older and younger age groups had similar levels of PTSD, older adults had a higher incidence of coexisting major depression (Livingston et al., 1 992). In the only study to date which assessed psychological sequelae in older victims of crime, participants reported moderate-to-severe levels of psychopathology, including excessive levels of depression and PTSD (Gray & Acierno,

2002). Another study revealed that older civilians experienced a stronger intensification of depressive mood in reaction to war stress when compared to younger civilians (Hobfoll, Lomranz, Eyal, Bridges, & Tzemach, 1 989). The conclusion made by Hobfoll and colleagues was that older adults do not disengage from their social surroundings as suggested by stereotypical beliefs about aging; instead they remain in touch with and react strongly to their environment. It is possible, however, that many of the older civilians in the study had memories of previous war-related trauma that were elicited as a result of current war stress. Studies of older people who have experienced past chronic trauma (i.e., war veterans, Holocaust survivors, prisoners-of-war) indicate that PTSD is

9 TRAUMA AND THE ELDERLY

highly comorbid with other psychopathological problems, including major depression, additional anxiety disorders, somatic conditions, cognitive disturbances and alcoholism (Averill & Beck, 2000).

Inconsistent research findings implicating aging as both a protective factor and a risk factor in posttraumatic stress may have been caused by variations in the constructs measured among studies (i.e., different psychological disorders) and varying methods o f evaluation. Nevertheless, the question of whether or not aging generates vulnerability or resiliency to trauma should not be the main issue. Deciphering how older adults experience traumatic stress and what symptoms prevail most frequently during later life is more important. In cases where trauma-related symptoms are reported less among older adults, literature still indicates the older people suffer just as much, if not more, than younger adults as a consequence of trauma. This is particularly clear when assessments have incorporated subjective measures of participants' responses. For example, studies have suggested that emotionally, older adults perceive themselves as coping less well than younger adults. Bolin and K.lenow ( 1 982) found that older survivors of a major tornado reported fewer psychological symptoms than younger survivors. However, although suffering from comparable material losses to younger survivors, older survivors reported a stronger sense of loss and deprivation, and felt less recovered after a year. Similarly, an investigation into I sraelis' responses to the Gulf War revealed that despite coping adequately on a practical level, older adults reported more difficulties coping emotionally. Older adults also reported greater levels of psychological distress as the war progressed than younger adults (Carmeli, Mevorach, Leiberman, et al., 1 992).

Contradictory research findings regarding the role of aging in posttraumatic stress reactions has increasingly prompted researchers to identify the specific trauma-related ailments most frequently elicited during later life. For example, in a study of earthquake survivors, aging was a predictor of more intense PTSD and depressive symptoms (Salcioglu, Basoglu, & Livanou, 2003), while in another study PTSD scores did not differ between younger and older earthquake survivors (Goenjian, Najarian, Pynoos, et al., 1 994). Further analyses of individual PTSD symptoms in these participants revealed

1 0

TRAUMA AND THE ELDERLY

that older adults experienced significantly higher levels of arousal and lower levels of intrusive and reexperiencing symptoms, when compared with their younger counterparts (Goenjian et al., 1 994).

In Gray and Acierno's (2002) study on psychological sequelae in older crime victims,

very few participants reported flashbacks. The most widely endorsed intrusive

symptoms were invasive thoughts, nightmares and distress when exposed to trauma­ related cues. Also reported frequently was behavioural avoidance of traumatic reminders and internal avoidance of trauma-related thoughts and emotions. Feeling isolated and detached from others, memory deficits relating to the trauma, restricted range of affect and sense of foreshortened future were also common.

Further research on the manifestation of traumatic stress during later life has indicated that older people experience more difficulties expressing emotion and higher levels of

survivor guilt (Hodgkinson & Stewart, 1 99 1 ) and hyper-arousal (Goenjian et al., 1 994).

Older adults frequently exhibit trauma-related symptoms somatically (Lipton & Schaffer,

1 986; Nichols & Czirr, 1 986) and are often inaccurately identified as having medical

concerns when suffering from trauma-related disorders such as PTSD (Lyons &

McClendon, 1 990). Associations between trauma exposure and health during later life have been revealed in a number of studies. Bowie's (2003) study of 225 older adults who had lost their houses to a hurricane revealed that many had multiple chronic health problems and required immediate medical and/or mental health assistance.

Comparisons between the above findings on acute traumatic stress reactions and research on older war-veterans indicates that posttraumatic stress may manifest similarly during later-life, whether trauma was recent or occurred during an earlier period of life. For instance, older war veterans who maintain elevated PTSD levels most frequently report persistent trauma-related thoughts, internal avoidance, as well as detachment, sleep and concentration difficulties, hyperarousal and depression (Blake, Nagy, Kaloupek, et al., 1 990). Especially salient among older veterans of World War II and the Korean and Vietnam Wars were symptoms of intense distress when exposed to trauma­ related cues and diminished interest in usual activities (Hyer, Summers, Braswell, &

1 1 TRAUMA AND THE ELDERLY

Boyd, 1 995). The association between trauma exposure and health has also been revealed in studies of older victims of past trauma. For example, Higgins and Follette (2002) observed that older female victims of past interpersonal trauma exhibited more health problems and took higher levels of medication than older females without such a history.

It seems, then, that regardless of when the trauma is endured, posttraurnatic stress reactions during later life may manifest as poor health and particularly high levels of hyperarousal and anxiety. Restricted range of affect, detachment, depression and difficulties expressing emotion may also be typical. Intense distress when reminded of trauma-related cues and internal avoidance of distressing feelings and thoughts are also common in older PTSD sufferers.

Differences in how symptoms are expressed between younger and o lder adults may be a fundamental reason why contradictions regarding aging and traumatic stress occur across studies. Assorted measures of PTSD and traumatic stress may vary in their focus on specific types of symptoms, generating inconsistencies. For example, Salcioglu and colleagues (2003) used a screening test to measure traumatic stress in a study that identified aging as a predictive factor in PTSD. However, Goenjian and colleagues ( 1 994) used DSM-IV criteria to assess PTSD symptoms and found no difference in PTSD scores across age groups. B ecause PTSD is an officially classified AP A disorder, it seems logical that PTSD assessment in studies use tools that are DSM-IV compatible. The current undertaking used a measure that corresponded with DSM-IV assessment of PTSD. This was expected to aid comparison of the present results with other studies using similar measures.

The above review suggests that, like younger adults, older people are susceptible to experiencing adverse psychological and physical reactions associated with trauma exposure. As discussed next, it is hypothesized that 'traumatic' events alone are not solely to blame for trauma-related difficulties during aging. Late-life stressors are also theorized to play a key role in triggering, enhancing and maintaining posttraumatic stress symptoms during aging.