Post-traumatic stress disorder and dementia in veterans: A scoping literature review

Posttraumatic Stress Disorder in Older Veterans admitted to VA Community Living Centers: Prevalence and Risk Correlates

OBJECTIVES

To examine prevalence and risk correlates for post-traumatic stress disorder (PTSD) occurring during or after admission to a Veterans Administration (VA) skilled nursing facility.

DESIGN

Retrospective cohort analysis of electronic health record information extracted from the VA Corporate Data Warehouse.

SETTING

United States VA skilled nursing facility.

PARTICIPANTS

57,414 Veterans age 60+ with an admission during five fiscal years, 2018-2022, excluding those who died within six months of admission or were still admitted.

MEASUREMENTS

The dependent variable was PTSD diagnosis during or six-months following the admission. Risk correlates examined were: age, gender, race, rurality, clinical complexity, prior dementia diagnosis, length of stay, and facility size; odds ratios (OR) and confidence intervals (CI) are provided for each correlate.

RESULTS

19.1% of Veterans had a diagnosis of PTSD, associated with younger age (age 60-69 compared to age 80+; OR: 2.92, 95% CI: 2.70-3.14; age 70-79 compared to age 80+ OR: 4.51, 95% CI: 4.20-4.84); female gender (OR: 1.65, 95% CI: 1.50-1.82); minoritized race (OR: 1.17, 95% CI: 1.12-1.23); higher clinical complexity (OR:1.22, 95% CI: 1.17-1.28). As compared to Veterans who had a prior PTSD diagnosis, Veterans with newly diagnosed PTSD were more likely to be older (age 60 group OR= 0.59, 95% CI:0.51-0.70; age 70 group OR= 0.54, 95% CI:0.46-0.62,), rural (OR=1.14, 95% CI:1.04-1.24) and admitted to a larger facility (OR=1.22, 95% CI:1.12-1.33).

CONCLUSIONS

PTSD is a significant concern for older Veterans admitted to VA skilled nursing facilities, supporting the need for trauma-informed care, particularly for those most at risk.

Involuntary Autobiographical Memory in Alzheimer's Disease: A Double-Edged Way of Remembering the Past?

Background

Alzheimer's disease (AD) is characterized by severe memory alterations, affecting especially memories of personal past events. Until now, autobiographical memory impairments have been characterized using formal memory assessments, requiring patients to strategically and deliberately recall past events. However, contrary to this highly cognitively demanding mode of memory recall, autobiographical memories frequently come to mind unexpectedly based on automatic associative processes. The involuntary recall of personal memories is effortless and possibly represents a preserved way for AD patients to remember past events.

Objective

This study aimed to investigate involuntary autobiographical memory in AD patients and compare the characteristics of these memories with those of healthy controls.

Methods

Involuntary autobiographical memory was measured in 24 AD patients and 24 matched control participants using self-report measures. Participants were asked to report the frequency with which involuntary autobiographical memories were experienced in their daily life and to describe and self-assess one example of an involuntary memory.

Results

We showed that AD patients and control participants did not differ in terms of the frequency or subjective characteristics of their involuntary autobiographical memories in daily life, except for feelings of intrusiveness. Compared to control participants, AD patients reported their involuntary autobiographical memories as being more intrusive. In addition, more negative and vague involuntary autobiographical memories were associated with greater depressive symptoms.

Conclusions

These findings open up a new avenue for research to better understand the extent to which involuntary autobiographical memory might be preserved in AD patients and why these memories may in turn become intrusive to patients.

Weaving Evidence into Action for Veterans with Dementia (WEAVE): Evaluation of implementation into long-term care practice

RATIONALE

Veterans living with dementia in long-term care have complex needs, with variable manifestation of symptoms of dementia that interact with their lived experience. Best practice dementia care prioritises nonpharmacological interventions; of which few have strong evidence. Implementation of evidence is complex, with evaluation of outcomes and processes necessary.

AIMS AND OBJECTIVES

This paper details the evaluation of implementation, at veteran and organisational level, of the Weaving Evidence into Action for Veterans with Dementia (WEAVE) programme.

METHODS

A Type 2 hybrid effectiveness-implementation design was used, underpinned by the Implementation Framework for Aged Care (IFAC). Programme intervention incorporated music therapy, exercise, reminiscence therapy and/or sensory modulation, offered over a 24-week period. Evaluation components included: (1) programme effectiveness for veterans with dementia for responsive behaviour, physical wellbeing, cognitive status, emotional state, medications and falls (at baseline, 8-week, 16-week and 24-week); and (2) implementation outcomes of reach and adoption, feasibility and acceptability, fidelity (via interviews) and a preliminary cost analysis.

RESULTS

Thirty-eight veterans participated in the 24-week programme, with high levels of engagement in interventions of their choice. Statistically significant improvements were seen across all veteran-level outcome measures, for functional capacity and reduced neuro-psychiatric and depressive symptoms. Ten staff members were interviewed, highlighting co-designed core elements were feasible and acceptable, and the momentum generated by resident and staff enthusiasm. Cost analysis included costs of programme set-up and running the 24-week intervention.

CONCLUSION

Key components of programme success were the therapeutic leaders, adherence to core elements of programme design, and veterans' choice in meaningful activity. Cost analysis supports deliberations for upscale across further care homes.

Weaving Evidence into Action for Veterans with dementia (WEAVE): Codesigning the implementation of nonpharmacological interventions for programme fidelity and sustainability

RATIONALE

Challenges associated with translating evidence into practice are well recognised and calls for effective strategies to reduce the time lag and successfully embed evidence-based practices into usual care are loud and clear. While a plethora of nonpharmacological interventions for people with dementia exist; few are based on strong evidence and there is little consideration for programme operationalisation in the complex environment of long-term care.

AIMS AND OBJECTIVES

This paper describes the preparation for the implementation of the Weaving Evidence into Action for Veterans with dementia project, incorporating the codesign of delivery of four evidence-based, nonpharmacological interventions.

METHOD

Implementation preparation for this type 2 hybrid effectiveness-implementation project was underpinned by the Implementation Framework for Aged Care (IFAC). A sociocultural-political contextual scan was undertaken, and reflection on the IFAC question 'why change?' with key stakeholders. Delivery of the four interventions of music therapy, exercise, reminiscence therapy and sensory modulation was explored using codesign methodology. Preparation of both intervention delivery personnel and recipients was via training, establishment of a change team and promotional/awareness-raising strategies.

RESULTS

The contextual scan revealed Australian government reforms and organisational imperatives facing long-term care services, while reflections on 'why change' flagged best practice dementia care at the local care home level. Several codesign sessions involved veterans with dementia, family members, care home staff members and volunteers to ensure programme alignment with needs and preferences, accounting for existing activities. Training was designed and delivered before programme commencement. A change team was established and strategies to support behaviour change instigated. Implementation evaluation is reported elsewhere.

CONCLUSION

The extended preparatory period for implementation, afforded by the COVID-19 pandemic on programme commencement, enabled time for widespread understanding of the programme and necessary upskill of staff. Comprehensive codesign with all stakeholders of programme components identified core and flexible elements necessary for fidelity of implementation.

Treatment of post-traumatic stress disorder in people with dementia: a structured literature review

Post-traumatic stress disorder (PTSD) is associated with cognitive dysfunctions and is an independent risk factor for dementia. A recent study has found the prevalence of PTSD in people with dementia is 4.7%-7.8%. However, little is known about the effectiveness of PTSD treatment for people with dementia. The primary aim of the current study is to review previous studies on the treatment of PTSD in people with dementia. A structured literature review was performed using a 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' analysis in PubMed, Embase, PsycINFO and CINAHL. Two independent researchers screened titles and abstracts. The inclusion criteria were: PTSD symptoms present, diagnosis of dementia, PTSD treatment form described and effects of the treatment mentioned. Articles that matched these criteria were included and content and quality were analyzed. We included nine articles, all case reports, with a total of 11 cases. The discussed treatment options are eye movement desensitisation and reprocessing (EMDR) (n = 3), prolonged exposure (n = 1), cognitive behavioural therapy (n = 1) and pharmacological treatment (n = 4). All articles reported a positive effect of the intervention on several monitored symptoms. Evidence for positive effects and feasibility of EMDR were most reliable, and it was applied in two articles of sufficient quality published in 2018 and 2019. EMDR 'on-the-spot' was described with positive effect in one article in which three cases were discussed. The quality of included papers ranged from insufficient to sufficient. This review shows that people with PTSD and dementia can benefit from PTSD treatment. EMDR, prolonged exposure, acceptance and commitment therapy and pharmacological treatment are applicable in this population. EMDR treatment is most described in this population (n = 5) and shows positive results, and the studies are of sufficient quality (n = 3). Further research in the form of a randomised controlled trial is required to study the effectivity of different treatment interventions in this population.

Treating Symptoms of Posttraumatic Stress in People with Dementia: Expert Consensus Using the Delphi Method

OBJECTIVES

Posttraumatic stress disorder is frequently present in people with dementia, but the symptoms are difficult to recognize and suitable treatments are lacking. The aim of the present study was to investigate which trauma-focused treatments are applicable to these patients.

METHODS

The Delphi method is a process which is used to reach consensus from a panel of experts. The study was conducted online and consisted of three rounds with statements about support for treatment, treatment, and implementation.

RESULTS

There are several treatment options available, but it depends on the symptoms, and the severity of PTSD and dementia which treatment is most suitable.

CONCLUSIONS

The outcomes offer some practical tips for health care workers, and they provide a fundamental base for future research.

CLINICAL IMPLICATIONS

Clinicians should pay attention to the treatment of PTSD symptoms in people with dementia and it is necessary to examine the type and severity of both PTSD symptoms and dementia. Taking these factors into account, clinicians are able to focus on the best treatment option in order to improve the quality of life of these specific type of patients.

Supporting Caregivers of Veterans with Dementia

As the number of veterans with dementia continues to increase, support services for those veterans and their caregivers must also increase. Caregivers of veterans with dementia often report high levels of emotional distress in the form of anxiety, exhaustion, and burden that negatively impacts their health and quality of life. This brief descriptive report highlights a Veterans Health Administration (VHA) project in which a social worker trained in palliative care, teaches stress-reduction to caregivers through individual counseling and virtual groups. In two years, 39 caregivers received individual assessment and counseling focused on stress-reduction. Also, five group webinars were held on the topic of self-care that averaged 17 caregivers per group. 24 caregivers completed a survey and results suggested that stress-reduction and self-care may be viable target areas of intervention for caregivers of veterans with dementia in both individual and group formats. More research is needed in this area to improve our knowledge of how stress may be reduced for caregivers and what type of interventions may be effective to help caregivers reduce stress and improve their self-care.

Nanowired Delivery of Cerebrolysin Together with Antibodies to Amyloid Beta Peptide, Phosphorylated Tau, and Tumor Necrosis Factor Alpha Induces Superior Neuroprotection in Alzheimer's Disease Brain Pathology Exacerbated by Sleep Deprivation

Sleep deprivation induces amyloid beta peptide and phosphorylated tau deposits in the brain and cerebrospinal fluid together with altered serotonin metabolism. Thus, it is likely that sleep deprivation is one of the predisposing factors in precipitating Alzheimer's disease (AD) brain pathology. Our previous studies indicate significant brain pathology following sleep deprivation or AD. Keeping these views in consideration in this review, nanodelivery of monoclonal antibodies to amyloid beta peptide (AβP), phosphorylated tau (p-tau), and tumor necrosis factor alpha (TNF-α) in sleep deprivation-induced AD is discussed based on our own investigations. Our results suggest that nanowired delivery of monoclonal antibodies to AβP with p-tau and TNF-α induces superior neuroprotection in AD caused by sleep deprivation, not reported earlier.

A first insight into the clinical manifestation of posttraumatic stress disorder in dementia: a systematic literature review

Posttraumatic stress disorder (PTSD) is a prevalent disorder worldwide and often co-occurs in dementia. Both have a major impact on disease burden and quality of life. PTSD may be difficult to recognize in dementia and a structured diagnostic method is lacking. In order to get insight into the clinical diagnostics of PTSD in dementia, this systematic literature review evaluates the clinical presentation of PTSD and other relevant symptoms in people with dementia. PubMed, PsycINFO, Embase, and CINAHL were searched for all publications through 30 December 2021. Articles were included which met the following criteria: (i) description of at least one case with a current diagnosis of dementia and co-morbid PTSD; (ii) clinical presentation of symptoms being adequately described; (iii) no difference being made between chronic PTSD, PTSD with re-activation, and delayed onset PTSD. Of the 947 identified abstracts, 13 papers met the inclusion criteria and were included (describing 30 cases). Based on our rating, only one case completely fulfilled the DSM-5 criteria of PTSD. Avoidance was only described in three cases. Most commonly described symptoms were irritability and anger (E1, 9%), persistent negative emotional state (D4, 9%), and sleep disturbances (E6, 8%). In 93% of the case reports, other symptoms were also described, i.e. memory problems (58%), screaming (33.3%), and wandering (22.2%). People with dementia who have experienced a traumatic event seem to present, based on our rating method, with insufficient symptoms to meet all criteria for a PTSD DSM-5 diagnosis. The DSM-5 core symptom of avoidance was absent in most of the cases. Clinical presentation consists mainly of symptoms of irritability, anger, persistent negative emotional state, and sleep disturbances, often accompanied by other symptoms. These findings suggest that older people with dementia may have other symptom presentations than people without dementia.

Understanding how Canadian healthcare providers have learned to identify co-occurring PTSD symptoms and dementia in Veterans

WHAT IS KNOWN ON THE SUBJECT?: Little is known about how PTSD and dementia in Veterans is identified by health care providers. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Healthcare providers identify those behavioural symptoms experienced by older people living with dementia that represent an unmet need associated with PTSD secondary to military service. Once healthcare providers recognize the presence of symptoms relevant to PTSD, they modify their care approach to include focused/tailored non-pharmacological care interventions that address environmental and situational variables that reflect military action. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Specialized education and training is needed to improve the identification of PTSD when existent with other co-occurring neurocognitive conditions such as delirium, dementia and depression. ABSTRACT: Introduction Co-occurring PTSD and dementia in Veterans can be difficult to distinguish from dementia-related responsive behaviours, which may result in inappropriate care management. Improved identification of PTSD and dementia is necessary to inform more appropriate and effective care for Veterans. Aim/Question The purpose of this study was to understand how Canadian healthcare providers have learned to identify the co-occurrence of PTSD symptoms in Veterans with dementia. Methods Eight semi-structured interviews employing the Critical Incident Technique were conducted with key informant healthcare providers who treat Veterans from across Canada. Framework analysis was used to code, sort and develop themes. Results Observed differences in Veterans with PTSD and dementia cued healthcare providers to seek our more information, leading to a new understanding of past trauma underlying the symptoms they observed. Healthcare providers then altered their usual care approaches to utilize trust-based and validation-oriented strategies resulting in more effective care management. Discussion Improvement in the identification of co-occurring PTSD and dementia in Veterans requires specialized education and training for healthcare providers. Implications for Practice Recognizing the complex needs of older Veterans with co-occurring PTSD and dementia is necessary for healthcare providers to implement more effective care for this population. Relevance Statement This paper provides mental health nurses with new understanding of co-occurring PTSD and dementia in Veterans. With an ageing Veteran population in Canada, mental health nurses need to be knowledgeable about the care for Veteran specific mental health needs.

Posttraumatic stress disorder in burn patient: A systematic review

INTRODUCTION

Burns often cause severe physical and mental suffering and can become a trigger for the development of permanent psychological diseases, even after wound healing. Posttraumatic stress disorder (PTSD) is one such disorder, which involves the re-experiencing of many symptoms provoked by a previous traumatic situation.

METHOD

This study is a systematic review of interventions used to reduce or prevent PTSD symptoms in burn victims. We included randomized clinical trials that described therapeutic interventions for the prevention of PTSD in burn patients. The search was conducted in the databases EMBASE and PUBMED/Medline between 2009 and 2020, and the main variables evaluated were%TBSA, age, number of hospitalization days, type of intervention, follow-up time and results. The analysis of the bias risk was carried out according to the guidance in the Cochrane Handbook for Bias Risk Assessment.

RESULTS

Eight clinical trials were selected: three of them were performed in children, and five involved adults. The most common bias risks were related to participant/researcher blinding and loss of follow-up. Two interventions were identified: a pharmacological intervention and a psychological intervention. Medications (sertraline and propanolol) were not effective in reducing stress symptoms. Four studies used cognitive-behavioral therapies, which achieved the best results for PTSD improvement in burn patients. Hypnosis and an informational education program were also evaluated and did not show success in reducing PTSD.

CONCLUSION

Cognitive-behavioral therapies may work to reduce PTSD symptoms in burn patients, and when they are adopted early by burn units, they may improve the psychological condition of burn patients.

PTSD Symptoms and Dementia in Older Veterans Who are Living in Long-Term Care

Co-occurring posttraumatic stress disorder symptoms and dementia can result in increased symptoms, such as suspicion, aggression, and nightmares in Veterans that can be difficult to manage in long-term care environments. The objective of the study was to explore how the co-occurrence of posttraumatic stress disorder symptoms and dementia are understood in Canadian Veterans who are living in long-term care. A descriptive multiple case study was conducted in two Veteran long-term care facilities in Canada. Data collection consisted of semi-structured interviews with Veterans, their family caregivers, and health care providers, non-participant observation, and a chart audit. Three major themes emerged relating to symptom expression and care approach: a) symptoms are the same but different; b) differences in the complexity of care; and c) added dimensions involved in care. The results of this study contribute foundational information about co-occurring posttraumatic and dementia symptoms that can inform policy, care approaches, and potential interventions.

Estrogenic Plants: to Prevent Neurodegeneration and Memory Loss and Other Symptoms in Women After Menopause

In mammals, sexual hormones such as estrogens play an essential role in maintaining brain homeostasis and function. Estrogen deficit in the brain induces many undesirable symptoms such as learning and memory impairment, sleep and mood disorders, hot flushes, and fatigue. These symptoms are frequent in women who reached menopausal age or have had ovariectomy and in men and women subjected to anti-estrogen therapy. Hormone replacement therapy alleviates menopause symptoms; however, it can increase cardiovascular and cancer diseases. In the search for therapeutic alternatives, medicinal plants and specific synthetic and natural molecules with estrogenic effects have attracted widespread attention between the public and the scientific community. Various plants have been used for centuries to alleviate menstrual and menopause symptoms, such as Cranberry, Ginger, Hops, Milk Thistle, Red clover, Salvia officinalis, Soy, Black cohosh, Turnera diffusa, Ushuva, and Vitex. This review aims to highlight current evidence about estrogenic medicinal plants and their pharmacological effects on cognitive deficits induced by estrogen deficiency during menopause and aging.

Vitamin C attenuates memory loss induced by post-traumatic stress like behavior in a rat model

Oxidative stress is associated with neuronal damage in many brain regions including the hippocampus; an area in the brain responsible of memory processing. Oxidative stress is also linked with many psychiatric conditions including post-traumatic stress disorder (PTSD). PTSD is triggered by traumatic experience and many PTSD patients show signs of memory impairment. Vitamin C is a water-soluble vitamin with antioxidant properties. Herein, we hypothesized that memory impairment observed during PTSD could be a result of oxidative stress in hippocampal tissues and that prophylactic vitamin C administration may reduce oxidative stress in the hippocampus and prevent memory impairment. The above hypothesis was tested in a rat model where PTSD-like behavior was induced through single prolonged stress (SPS). Short and long-term memory was tested using a radial arm water maze (RAWM). We found that SPS induced a significant increase in the oxidized glutathione levels of the hippocampus. This reduction was accompanied with a significant decrease in glutathione peroxidase and catalase enzyme activity, and a significant increase in lipid peroxidation. Intriguingly, vitamin C administration successfully attenuated memory impairment and all of the changes observed in oxidative stress markers. Our findings demonstrate that vitamin C could prevent oxidative stress and memory impairment induced by SPS model of PTSD-like behavior in rat.