Approximately 70 percent of adults aged 60 years and older will experience a psychologically traumatic event in their lifetime (Ogle et al., 2014). As clinicians we understand the fundamental impacts that these experiences can have on function and well-being. These effects extend and can compound into late life and can influence a survivor’s sense of safety while receiving elder care. Delivering safe and accessible care for older trauma survivors can be a challenge when care providers are time constrained and undertrained in meeting mental health needs. This Clinician’s Corner will describe what is known about how psychological trauma affects the experience of aging and receiving elder care, how implementing trauma-informed care can benefit older survivors, and practical steps that care providers can take toward implementation.
Epidemiological evidence demonstrates that exposure to traumatic events is very common among older people, and somewhere between 2-10% will meet criteria for posttraumatic stress disorder (PTSD) at some time in their life (Cook & Simiola, 2017). Even without PTSD, or after recovery, the impacts of traumatic events tend to persist or are at least present intermittently over the lifetime. There are several reasons for this. People who experience traumatic events can develop insufficient or maladaptive coping strategies and harmful core beliefs that can accumulate and compound with other problems over time. Difficulty regulating emotions and trusting others (including service providers) can limit access to social networks that are protective for late life well-being. Coping and avoidance strategies developed and entrenched over the lifespan can become more difficult to use in late life (e.g., overcommitting to work, avoiding a particular landmark when unable to drive self; Maschi et al., 2013).
Older survivors report higher rates of psychological illness, substance use disorders, and suicidality than those not exposed to trauma (Maschi et al., 2013). At a population level, trauma survivors reach late life with fewer protective social networks, poorer health, fewer financial resources, and more difficulty coping with illness and pain (Maschi et al., 2013). Neurobiological effects of persistent traumatic stress can include a chronic overproduction of glucocorticoids, hippocampal atrophy, and possibly an increased risk for dementia (Desmarais et al., 2019). Importantly, older people and people with dementia can experience the re-emergence of traumatic stress symptoms even when these symptoms have been dormant for many years (Desmarais et al., 2019). Given these impacts, it should be expected that psychological trauma will influence the experience of receiving elder care services in important ways.
Older people are frequent users of health and social care services and will interact with multiple care providers and services in any given year. Professionals working within mental health services should be familiar with the ways in which psychological trauma can contribute to treatment resistance, distrust for care providers, and withdrawn or dysregulated behavior in this population. Recent research, including from our team, indicates that these impacts understandably continue when accessing elder care services as well. For example, older Holocaust survivors are sensitive to re-traumatization from common aged care practices and environments, including locked wards, personal care, and shared meals (Teshuva & Wells, 2014). Older people who experienced childhood abuse find the limitations to choice and control imposed by elder care services profoundly distressing, and often delay accessing care (Brown-Yung et al., 2021). Symptoms of traumatic stress (‘triggering’ or emotion dysregulation) can be confused for behavioral and psychological symptoms of dementia, which are too often managed using physical or chemical restraint (Bruneau et al., 2020). From this perspective, there is a strong case to be made for the widespread implementation of trauma-informed models of care into elder care settings. Trauma-informed care was developed within and proliferates in mental health services, particularly in the United States. Trauma-informed care does not propose that all care providers should treat the symptoms of traumatic stress. Rather, in trauma-informed care settings all staff (including indirect staff like administration or food services) are aware of the potential impact of trauma, can identify signs of distress, adapt practices and procedures to promote safety, and provide an environment which maximizes a sense of control for the care recipient (Harris & Fallot, 2001).
Trauma-informed care is a relatively uncharacterized and innovative approach with little published evidence in elder care settings. Our recent research has attempted to understand what care processes and behaviors would need to be implemented to deliver trauma-informed elder care (de la Perrelle et al., 2022). These might include:
- Education for all staff about psychological trauma and its ongoing effects
- Redressing power imbalances between care provider and recipient by restoring control and choice to the care recipient wherever possible. This might include the availability of choices about food, activities, locked or unlocked doors, care provider, and so on.
- Implementing processes that offer care recipients the opportunity to safely disclose triggers that make them feel distressed and coping strategies that help them to return to calm.
- Building ‘vertical’ information sharing systems that allow staff who have the most contact with care recipients (e.g., direct care workers, cleaners) to share information that they learn about a recipients’ triggers and coping strategies.
- Creating care environments that enable calm, quiet, and unhurried care.
- Maintaining clear referral pathways to mental health supports where needed, and ensuring all staff are aware of how to access these supports.
Of course, the elder care workforce generally receives very little training in mental health, are under pressure to deliver nursing and personal care with limited resources, and in many countries contend with a shortage of mental health professionals working in elder care settings. As clinicians with expertise in the assessment and management of traumatic stress, we can contribute to this effort and support those with less training and expertise than us. We do this by:
- Providing education, mentoring, and modeling in the delivery of trauma-informed care to elder care staff.
- Helping care staff to conceptualize care recipient behavior and build empathy, by “connecting the dots.”
- Offering validation and emotional care for the impact of recipient behavior that is distressing to professionals.
- Encouraging elder care professionals to take a strengths-based approach and recognize the enduring resilience of the survivor.
Older trauma survivors encapsulate the meaning of the word “survivor.” Implementing trauma-informed models of care throughout elder care settings can ensure that older adults can continue to build their strengths while reducing their risk for re-traumatization and harm.
About the Author
Dr Monica Cations, BPsych(Hons), MPsych(Clin), PhD is a clinical psychologist and epidemiologist who conducts translational research and clinical practice with older adults and people living with dementia. Her research focuses on improving the quality and safety of aged care, particularly for those with complex mental health needs and psychological trauma. Monica is a Senior Research Fellow in the College of Education, Psychology and Social Work at Flinders University, supported by a Hospital Research Foundation Early Career Fellowship and NHMRC/MRFF Emerging Leadership Investigator Grant.
References
Browne-Yung, K., O’Neil, D., Walker, R., Smyth, A., Putsey, P., Corlis, M.,Laver, K., Fernandez, E., & Cations, M. (2021). ‘I’d rather die in the middle of a street’: Perceptions and expectations of aged care among forgotten Australians. Australasian Journal on Ageing, 40, 168-176.
Bruneau, M. A., Desmarais, P., & Pokrzywko, K. (2020). Post-traumatic stress disorder mistaken for behavioural and psychological symptoms of dementia: Case series and recommendations of care. Psychogeriatrics, 20, 754-759.
Cook, J. M., & Simiola, V. (2017). Trauma and PTSD in older adults: Prevalence, course, concomitants, and clinical considerations. Current Opinion in Psychology, 14, 1-4.
de la Perrelle, L., Klinge, N., Windsor, T. D., Low, L. F., Laver, K., & Cations, M. (2022). Characterizing trauma-informed aged care: An appreciative inquiry approach. International Journal of Geriatric Psychiatry. Online ahead of print.
Desmarais, P., Weidman, D., Wassef, A., Bruneau, M. A., Friedland, J., Bajsarowicz, P., Thibodeau, M-P., Herrmann, N., & Nguyen, Q. D. (2020). The interplay between post-traumatic stress disorder and dementia: A systematic review. American Journal of Geriatric Psychiatry, 28, 48-60.
Harris, M., & Fallot, R. D. (2001). Envisioning a trauma-informed service system: A vital paradigm shift. New Directions for Mental Health Services, 2001, 3-22.
Maschi, T., Baer, J., Morrissey, M., & Moreno, C. (2013). The aftermath of childhood trauma on late life mental and physical health: A review of the literature. Traumatology, 19, 49-64.
Ogle C. M., Rubin D. C., & Siegler, I. C. (2014). Cumulative exposure to traumatic events in older adults. Aging & Mental Health, 18(3):316–25.
Teshuva, K., & Wells, Y. (2014). Experiences of aging and aged care in Australia of older survivors of genocide. Ageing and Society, 34, 518-537.