Caroline is an 80-year-old Black woman, widow and grandmother. She had a heart attack at age 66 and now has atrial fibrillation. She also has chronic low back pain and symptomatic osteoarthritis in both knees and hands, hearing loss and macular degeneration in both eyes.
Seen in urgent care clinic after a fall in her home with no injuries, the provider muses that she should probably stop taking Apixaban (used to treat atrial fibrillation to reduce stroke and risk of blood clots) because of bleeding risk. Her daughter is present for that clinic visit, visibly worried that her mother isn’t safe to remain in her home.
You see Caroline a few months later in clinic. She is experiencing worsened back, hand and knee pain that is affecting her ability to navigate her stairs. Too uncomfortable to walk her usual route around her neighborhood, she has spent most of her days during the last few months at home. She has lost interest in some of her previous hobbies because she hasn’t been able to venture out to replenish supplies. Her sleep has become fragmented and she is napping once during the day now because she gets so tired. Her daughter and son have been pressuring her to move to an assisted living residence and she appears sad and angry while mentioning this.
Getting to the Root of the Issue
You sit back to ask, “How are you doing?” and Caroline starts to cry. Both her mother and her partner died in nursing homes after long periods of institutionalization. Caroline saw “the light go out of their eyes” while they lived in that setting, and promised herself that she would never follow the same path. This is what has driven her to maintain her mobility as much as possible and to keep up with her hobbies.
Patients who are carrying trauma are the rule, not the exception.
She already has tried to adapt her routines to life with diminished vision and hearing and now worries it may be impossible to meet her goals. Every day she tells herself that she is going to walk her usual route but finds excuses for why she can’t. She talks about feeling her life “chipped away” by serial losses of her partner, her vision and hearing and now possibly her home. She is having nightmares that disrupt her sleep and her pain experience has worsened.
You recognize that at the root of her symptoms is trauma. In the short term, she is dealing with fear of falling, which is an independent risk factor for future falls, and profound fear of loss of independence. She also is reliving previous traumatic experiences caring for her mother and partner at the ends of their lives, and of losing her partner.
- “For almost no one is exempt from trauma. While some people have it in a much more pronounced way than others, the unpredictable and unstable nature of things makes life inherently traumatic.” —Dr. Mark Epstein
Trauma is part of being alive. It also leaves nicks and dings on us that make each person uniquely strong and vulnerable. It stands to reason that the longer the life, the more nicks and dings may be present. What this tells us is that those lucky enough to live to older adulthood bring with them lifetimes of everyday traumas that can re-emerge in the present. Up to 90% of older adults have been exposed to at least one traumatic event in their lives, and this statistic eclipses the estimated 5% prevalence of formal PTSD diagnoses.
It also has been postulated that subsyndromal PTSD, or states that do not fulfill all the diagnostic criteria for PTSD, is more common than previously thought among older adults. Taken together, this suggests that there should be a presumption among providers that older adults seeking care have at least one traumatic exposure in their past, regardless of formal diagnosis. These patients are the rule, not the exception.
Older adults also are not immune to accumulating new traumas later in life. Many factors associated with resilience, such as connection to a religious or spiritual practice, social connectedness and life perspective, are associated with older adulthood, but this does not confer imperviousness to new traumas. These embedded resilience promotors come up against everyday traumas unique to later life, including retirement, medical illness, loss of a spouse, friends or other close family members and changes to functional independence. Even something seemingly simple like fear of falling can have outsized ripple effects in multiple domains of life.
Stepping back even further, older adults are just as vulnerable to traumatic responses to current events like natural disasters or mass shootings. Also, these events may trigger re-emergence of past trauma among survivors of previous disasters. This is important for first responders and humanitarian organizations to recognize when they are providing care for older adults who are in harm’s way, and for all providers to recognize and address signs of acute trauma among older survivors of everyday or exceptional traumatic events.
Is there an age at which we become “too old” to experience trauma? No. Our lived experiences can boost our resiliency and help put events in perspective, but we remain just as sensitive to new and re-emerged traumas in the everyday and the exceptional.
Kathleen Drago, MD, is an assistant professor of medicine in the division of General Internal Medicine and Geriatrics at Oregon Health and Science University in Portland, Ore.
Photo credit: Shutterstock/GD Arts