����JFIFXX�����    $.' ",#(7),01444'9=82<.342  2!!22222222222222222222222222222222222222222222222222����"��4�� ���,�PG"Z_�4�˷����kjز�Z�,F+��_z�,�© �����zh6�٨�ic�fu���#ډb���_�N�?��wQ���5-�~�I���8����TK<5o�Iv-�����k�_U_�����~b�M��d����Ӝ�U�Hh��?]��E�w��Q���k�{��_}qFW7HTՑ��Y��F�?_�'ϔ��_�Ջt��=||I ��6�έ"�����D���/[�k�9���Y�8ds|\���Ҿp6�Ҵ���]��.����6�z<�v��@]�i%��$j��~�g��J>��no����pM[me�i$[����s�o�ᘨ�˸ nɜG-�ĨU�ycP�3.DB�li�;��hj���x7Z^�N�h������N3u{�:j�x�힞��#M&��jL P@_���� P��&��o8������9�����@Sz6�t7#O�ߋ �s}Yf�T���lmr����Z)'N��k�۞p����w\�Tȯ?�8`�O��i{wﭹW�[�r�� ��Q4F�׊���3m&L�=��h3����z~��#�\�l :�F,j@�� ʱ�wQT����8�"kJO���6�֚l����}���R�>ډK���]��y����&����p�}b��;N�1�m�r$�|��7�>e�@B�TM*-iH��g�D�)� E�m�|�ؘbҗ�a��Ҿ����t4���o���G��*oCN�rP���Q��@z,|?W[0�����:�n,jWiE��W��$~/�hp\��?��{(�0���+�Y8rΟ�+����>S-S����VN;�}�s?.����� w�9��˟<���Mq4�Wv'��{)0�1mB��V����W[�����8�/<� �%���wT^�5���b��)iM� pg�N�&ݝ��VO~�q���u���9� ����!��J27����$O-���! �:�%H��� ـ����y�ΠM=t{!S�� oK8������t<����è:a������[�����ա�H���~��w��Qz`�po�^ ����Q��n� �,uu�C�$ ^���,������8�#��:�6��e�|~���!�3�3.�\0��q��o�4`.|� ����y�Q�`~;�d�ׯ,��O�Zw�������`73�v�܋�<���Ȏ�� ـ4k��5�K�a�u�=9Yd��$>x�A�&�� j0� ���vF��� Y�|�y��� ~�6�@c��1vOp�Ig����4��l�OD���L����� R���c���j�_�uX6��3?nk��Wy�f;^*B� ��@�~a�`��Eu������+���6�L��.ü>��}y���}_�O�6�͐�:�YrG�X��kG�����l^w���~㒶sy��Iu�!� W ��X��N�7BV��O��!X�2����wvG�R�f�T#�����t�/?���%8�^�W�aT��G�cL�M���I��(J����1~�8�?aT ���]����AS�E��(��*E}� 2��#I/�׍qz��^t�̔���b�Yz4x���t�){ OH��+(E��A&�N�������XT��o��"�XC��'���)}�J�z�p� ��~5�}�^����+�6����w��c��Q�|Lp�d�H��}�(�.|����k��c4^�"�����Z?ȕ ��a<�L�!039C� �Eu�C�F�Ew�ç ;�n?�*o���B�8�bʝ���'#Rqf���M}7����]����s2tcS{�\icTx;�\��7K���P���ʇ Z O-��~��c>"��?�������P��E��O�8��@�8��G��Q�g�a�Վ���󁶠�䧘��_%#r�>�1�z�a��eb��qcPѵ��n���#L��� =��׀t� L�7�`��V���A{�C:�g���e@�w1 Xp3�c3�ġ����p��M"'-�@n4���fG��B3�DJ�8[Jo�ߐ���gK)ƛ��$���� ���8�3�����+���� �����6�ʻ���� ���S�kI�*KZlT _`���?��K����QK�d����B`�s}�>���`��*�>��,*@J�d�oF*����弝��O}�k��s��]��y�ߘ��c1G�V���<=�7��7����6�q�PT��tXԀ�!9*4�4Tހ3XΛex�46���Y��D ����� �BdemDa����\�_l,��G�/���֌7���Y�](�xTt^%�GE�����4�}bT���ڹ�����;Y)���B�Q��u��>J/J �⮶.�XԄ��j�ݳ�+E��d ��r�5�_D�1 ��o�� �B�x�΢�#���<��W�����8���R6�@g�M�.��� dr�D��>(otU��@x=��~v���2� ӣ�d�oBd��3�eO�6�㣷�����ݜ6��6Y��Qz`��S��{���\P�~z m5{J/L��1������<�e�ͅPu�b�]�ϔ���'������f�b� Zpw��c`"��i���BD@:)ִ�:�]��hv�E�w���T�l��P���"Ju�}��وV J��G6��. J/�Qgl߭�e�����@�z�Zev2u�)]կ�����7x���s�M�-<ɯ�c��r�v�����@��$�ޮ}lk���a���'����>x��O\�ZFu>�����ck#��&:��`�$�ai�>2Δ����l���oF[h��lE�ܺ�Πk:)���`�� $[6�����9�����kOw�\|���8}������ބ:��񶐕��I�A1/�=�2[�,�!��.}gN#�u����b��� ~��݊��}34q����d�E��Lc��$��"�[q�U�硬g^��%B �z���r�pJ�ru%v\h1Y�ne`ǥ:g���pQM~�^�Xi� ��`S�:V29.�P���V�?B�k�� AEvw%�_�9C�Q����wKekPؠ�\�;Io d�{ ߞo�c1eP����\� `����E=���@K<�Y���eڼ�J���w����{av�F�'�M�@/J��+9p���|]�����Iw &`��8���&M�hg��[�{��Xj��%��Ӓ�$��(����ʹN���<>�I���RY���K2�NPlL�ɀ)��&e����B+ь����( � �JTx���_?EZ� }@ 6�U���뙢ط�z��dWI�n` D����噥�[��uV��"�G&Ú����2g�}&m��?ċ�"����Om#��������� ��{�ON��"S�X��Ne��ysQ���@Fn��Vg���dX�~nj�]J�<�K]:��FW��b�������62�=��5f����JKw��bf�X�55��~J �%^����:�-�QIE��P��v�nZum� z � ~ə ���� ���ة����;�f��\v���g�8�1��f24;�V���ǔ�)����9���1\��c��v�/'Ƞ�w�������$�4�R-��t���� e�6�/�ġ �̕Ecy�J���u�B���<�W�ַ~�w[B1L۲�-JS΂�{���΃������A��20�c#��@ 0!1@AP"#2Q`$3V�%45a6�FRUq��� ����^7ׅ,$n�������+��F�`��2X'��0vM��p�L=������5��8������u�p~���.�`r�����\���O��,ư�0oS ��_�M�����l���4�kv\JSd���x���SW�<��Ae�IX����������$I���w�:S���y���›R��9�Q[���,�5�;�@]�%���u�@ *ro�lbI �� ��+���%m:�͇ZV�����u�̉����θau<�fc�.����{�4Ա� �Q����*�Sm��8\ujqs]{kN���)qO�y�_*dJ�b�7���yQqI&9�ԌK!�M}�R�;������S�T���1���i[U�ɵz�]��U)V�S6���3$K{�ߊ<�(� E]Զ[ǼENg�����'�\?#)Dkf��J���o��v���'�%ƞ�&K�u�!��b�35LX�Ϸ��63$K�a�;�9>,R��W��3�3� d�JeTYE.Mϧ��-�o�j3+y��y^�c�������VO�9NV\nd�1 ��!͕_)a�v;����թ�M�lWR1��)El��P;��yوÏ�u 3�k�5Pr6<�⒲l�!˞*��u־�n�!�l:����UNW ��%��Chx8vL'��X�@��*��)���̮��ˍ��� ���D-M�+J�U�kvK����+�x8��cY������?�Ԡ��~3mo��|�u@[XeY�C�\Kp�x8�oC�C�&����N�~3-H���� ��MX�s�u<`���~"WL��$8ξ��3���a�)|:@�m�\���^�`�@ҷ)�5p+��6���p�%i)P M���ngc�����#0Aruz���RL+xSS?���ʮ}()#�t��mˇ!��0}}y����<�e� �-ή�Ԩ��X������ MF���ԙ~l L.3���}�V뽺�v�����멬��Nl�)�2����^�Iq��a��M��qG��T�����c3#������3U�Ǎ���}��לS�|qa��ڃ�+���-��2�f����/��bz��ڐ�� �ݼ[2�ç����k�X�2�* �Z�d���J�G����M*9W���s{��w���T��x��y,�in�O�v��]���n����P�$�JB@=4�OTI�n��e�22a\����q�d���%�$��(���:���: /*�K[PR�fr\nڙdN���F�n�$�4�[�� U�zƶ����� �mʋ���,�ao�u 3�z� �x��Kn����\[��VFmbE;�_U��&V�Gg�]L�۪&#n%�$ɯ�dG���D�TI=�%+AB�Ru#��b4�1�»x�cs�YzڙJG��f��Il��d�eF'T� iA��T���uC�$����Y��H?����[!G`}���ͪ� �纤Hv\������j�Ex�K���!���OiƸ�Yj�+u-<���'q����uN�*�r\��+�]���<�wOZ.fp�ێ��,-*)V?j-kÊ#�`�r��dV����(�ݽBk�����G�ƛk�QmUڗe��Z���f}|����8�8��a���i��3'J�����~G_�^���d�8w������ R�`(�~�.��u���l�s+g�bv���W���lGc}��u���afE~1�Ue������Z�0�8�=e�� f@/�jqEKQQ�J��oN��J���W5~M>$6�Lt�;$ʳ{���^��6�{����v6���ķܰg�V�cnn �~z�x�«�,2�u�?cE+Ș�H؎�%�Za�)���X>uW�Tz�Nyo����s���FQƤ��$��*�&�LLXL)�1�" L��eO��ɟ�9=���:t��Z���c��Ž���Y?�ӭV�wv�~,Y��r�ۗ�|�y��GaF�����C�����.�+� ���v1���fήJ�����]�S��T��B��n5sW}y�$��~z�'�c ��8 ��� ,! �p��VN�S��N�N�q��y8z˱�A��4��*��'������2n<�s���^ǧ˭P�Jޮɏ�U�G�L�J�*#��<�V��t7�8����TĜ>��i}K%,���)[��z�21z ?�N�i�n1?T�I�R#��m-�����������������1����lA�`��fT5+��ܐ�c�q՝��ʐ��,���3�f2U�եmab��#ŠdQ�y>\��)�SLY����w#��.���ʑ�f��� ,"+�w�~�N�'�c�O�3F�������N<���)j��&��,-� �љ���֊�_�zS���TǦ����w�>��?�������n��U仆�V���e�����0���$�C�d���rP �m�׈e�Xm�Vu� �L��.�bֹ��� �[Դaզ���*��\y�8�Է:�Ez\�0�Kq�C b��̘��cө���Q��=0Y��s�N��S.���3.���O�o:���#���v7�[#߫ ��5�܎�L���Er4���9n��COWlG�^��0k�%<���ZB���aB_���������'=��{i�v�l�$�uC���mƎҝ{�c㱼�y]���W�i ��ߧc��m�H� m�"�"�����;Y�ߝ�Z�Ǔ�����:S#��|}�y�,/k�Ld� TA�(�AI$+I3��;Y*���Z��}|��ӧO��d�v��..#:n��f>�>���ȶI�TX��� 8��y����"d�R�|�)0���=���n4��6ⲑ�+��r<�O�܂~zh�z����7ܓ�HH�Ga롏���nCo�>������a ���~]���R���̲c?�6(�q�;5%� |�uj�~z8R=X��I�V=�|{v�Gj\gc��q����z�؋%M�ߍ����1y��#��@f^���^�>N�����#x#۹��6�Y~�?�dfPO��{��P�4��V��u1E1J �*|���%���JN��`eWu�zk M6���q t[�� ��g�G���v��WIG��u_ft����5�j�"�Y�:T��ɐ���*�;� e5���4����q$C��2d�}���� _S�L#m�Yp��O�.�C�;��c����Hi#֩%+) �Ӎ��ƲV���SYź��g |���tj��3�8���r|���V��1#;.SQ�A[���S������#���`n�+���$��$I �P\[�@�s��(�ED�z���P��])8�G#��0B��[ى��X�II�q<��9�~[Z멜�Z�⊔IWU&A>�P~�#��dp<�?����7���c��'~���5 ��+$���lx@�M�dm��n<=e�dyX��?{�|Aef ,|n3�<~z�ƃ�uۧ�����P��Y,�ӥQ�*g�#먙R�\���;T��i,��[9Qi歉����c>]9�� ��"�c��P�� �Md?٥��If�ت�u��k��/����F��9�c*9��Ǎ:�ØF���z�n*�@|I�ށ9����N3{'��[�'ͬ�Ҳ4��#}��!�V� Fu��,�,mTIk���v C�7v���B�6k�T9��1�*l� '~��ƞF��lU��'�M ����][ΩũJ_�{�i�I�n��$���L�� j��O�dx�����kza۪��#�E��Cl����x˘�o�����V���ɞ�ljr��)�/,�߬h�L��#��^��L�ф�,íMƁe�̩�NB�L�����iL����q�}��(��q��6IçJ$�W�E$��:������=#����(�K�B����zђ <��K(�N�۫K�w��^O{!����)�H���>x�������lx�?>Պ�+�>�W���,Ly!_�D���Ō�l���Q�!�[ �S����J��1��Ɛ�Y}��b,+�Lo�x�ɓ)����=�y�oh�@�꥟/��I��ѭ=��P�y9��� �ۍYӘ�e+�p�Jnϱ?V\SO%�(�t� ���=?MR�[Ș�����d�/ ��n�l��B�7j� ��!�;ӥ�/�[-���A�>�dN�sLj ��,ɪv��=1c�.SQ�O3�U���ƀ�ܽ�E����������̻��9G�ϷD�7(�}��Ävӌ\�y�_0[w ���<΍>����a_��[0+�L��F.�޺��f�>oN�T����q;���y\��bՃ��y�jH�<|q-eɏ�_?_9+P���Hp$�����[ux�K w�Mw��N�ی'$Y2�=��q���KB��P��~������Yul:�[<����F1�2�O���5=d����]Y�sw:���Ϯ���E��j,_Q��X��z`H1,#II ��d�wr��P˂@�ZJV����y$�\y�{}��^~���[:N����ߌ�U�������O��d�����ؾe��${p>G��3c���Ė�lʌ�� ת��[��`ϱ�-W����dg�I��ig2��� ��}s ��ؤ(%#sS@���~���3�X�nRG�~\jc3�v��ӍL��M[JB�T��s3}��j�Nʖ��W����;7��ç?=X�F=-�=����q�ߚ���#���='�c��7���ڑW�I(O+=:uxq�������������e2�zi+�kuG�R��������0�&e�n���iT^J����~\jy���p'dtG��s����O��3����9* �b#Ɋ�� p������[Bws�T�>d4�ۧs���nv�n���U���_�~,�v����ƜJ1��s�� �QIz��)�(lv8M���U=�;����56��G���s#�K���MP�=��LvyGd��}�VwWBF�'�à �?MH�U�g2�� ����!�p�7Q��j��ڴ����=��j�u��� Jn�A s���uM������e��Ɔ�Ҕ�!)'��8Ϣ�ٔ��ޝ(��Vp���צ֖d=�IC�J�Ǡ{q������kԭ�߸���i��@K����u�|�p=..�*+����x�����z[Aqġ#s2a�Ɗ���RR�)*HRsi�~�a &f��M��P����-K�L@��Z��Xy�'x�{}��Zm+���:�)�) IJ�-i�u���� ���ܒH��'�L(7�y�GӜq���� j��� 6ߌg1�g�o���,kر���tY�?W,���p���e���f�OQS��!K�۟cҒA�|ս�j�>��=⬒��˧L[�� �߿2JaB~R��u�:��Q�] �0H~���]�7��Ƽ�I���(}��cq '�ήET���q�?f�ab���ӥvr� �)o��-Q��_'����ᴎo��K������;��V���o��%���~OK ����*��b�f:���-ťIR��`B�5!RB@���ï�� �u �̯e\�_U�_������� g�ES��3�������QT��a����x����U<~�c?�*�#]�MW,[8O�a�x��]�1bC|踤�P��lw5V%�)�{t�<��d��5���0i�XSU��m:��Z�┵�i�"��1�^B�-��P�hJ��&)O��*�D��c�W��vM��)����}���P��ܗ-q����\mmζZ-l@�}��a��E�6��F�@��&Sg@���ݚ�M����� ȹ 4����#p�\H����dYDo�H���"��\��..R�B�H�z_�/5˘����6��KhJR��P�mƶi�m���3�,#c�co��q�a)*Pt����R�m�k�7x�D�E�\Y�閣_X�<���~�)���c[[�BP����6�Yq���S��0����%_����;��Àv�~�| VS؇ ��'O0��F0��\���U�-�d@�����7�SJ*z��3n��y��P����O���������m�~�P�3|Y��ʉr#�C�<�G~�.,! ���bqx���h~0=��!ǫ�jy����l�O,�[B��~��|9��ٱ����Xly�#�i�B��g%�S��������tˋ���e���ې��\[d�t)��.+u�|1 ������#�~Oj����hS�%��i.�~X���I�H�m��0n���c�1uE�q��cF�RF�o���7� �O�ꮧ� ���ۛ{��ʛi5�rw?׌#Qn�TW��~?y$��m\�\o����%W� ?=>S�N@�� �Ʈ���R����N�)�r"C�:��:����� �����#��qb��Y�. �6[��2K����2u�Ǧ�HYR��Q�MV��� �G�$��Q+.>�����nNH��q�^��� ����q��mM��V��D�+�-�#*�U�̒ ���p욳��u:�������IB���m���PV@O���r[b= �� ��1U�E��_Nm�yKbN�O���U�}�the�`�|6֮P>�\2�P�V���I�D�i�P�O;�9�r�mAHG�W�S]��J*�_�G��+kP�2����Ka�Z���H�'K�x�W�MZ%�O�YD�Rc+o��?�q��Ghm��d�S�oh�\�D�|:W������UA�Qc yT�q������~^�H��/��#p�CZ���T�I�1�ӏT����4��"�ČZ�����}��`w�#�*,ʹ�� ��0�i��課�Om�*�da��^gJ݅{���l�e9uF#T�ֲ��̲�ٞC"�q���ߍ ոޑ�o#�XZTp����@ o�8��(jd��xw�]�,f���`~�|,s��^����f�1���t��|��m�򸄭/ctr��5s��7�9Q�4�H1꠲BB@l9@���C�����+�wp�xu�£Yc�9��?`@#�o�mH�s2��)�=��2�.�l����jg�9$�Y�S�%*L������R�Y������7Z���,*=�䷘$�������arm�o�ϰ���UW.|�r�uf����IGw�t����Zwo��~5 ��YյhO+=8fF�)�W�7�L9lM�̘·Y���֘YLf�큹�pRF���99.A �"wz��=E\Z���'a� 2��Ǚ�#;�'}�G���*��l��^"q��+2FQ� hj��kŦ��${���ޮ-�T�٭cf�|�3#~�RJ����t��$b�(R��(����r���dx� >U b�&9,>���%E\� Ά�e�$��'�q't��*�א���ެ�b��-|d���SB�O�O��$�R+�H�)�܎�K��1m`;�J�2�Y~9��O�g8=vqD`K[�F)k�[���1m޼c��n���]s�k�z$@��)!I �x՝"v��9=�ZA=`Ɠi �:�E��)`7��vI��}d�YI�_ �o�:ob���o ���3Q��&D&�2=�� �Ά��;>�h����y.*ⅥS������Ӭ�+q&����j|UƧ����}���J0��WW< ۋS�)jQR�j���Ư��rN)�Gű�4Ѷ(�S)Ǣ�8��i��W52���No˓� ۍ%�5brOn�L�;�n��\G����=�^U�dI���8$�&���h��'���+�(������cȁ߫k�l��S^���cƗjԌE�ꭔ��gF���Ȓ��@���}O���*;e�v�WV���YJ\�]X'5��ղ�k�F��b 6R�o՜m��i N�i����>J����?��lPm�U��}>_Z&�KK��q�r��I�D�Չ~�q�3fL�:S�e>���E���-G���{L�6p�e,8��������QI��h��a�Xa��U�A'���ʂ���s�+טIjP�-��y�8ۈZ?J$��W�P� ��R�s�]��|�l(�ԓ��sƊi��o(��S0��Y� 8�T97.�����WiL��c�~�dxc�E|�2!�X�K�Ƙਫ਼�$((�6�~|d9u+�qd�^3�89��Y�6L�.I�����?���iI�q���9�)O/뚅����O���X��X�V��ZF[�یgQ�L��K1���RҖr@v�#��X�l��F���Нy�S�8�7�kF!A��sM���^rkp�jP�DyS$N���q��nxҍ!U�f�!eh�i�2�m���`�Y�I�9r�6� �TF���C}/�y�^���Η���5d�'��9A-��J��>{�_l+�`��A���[�'��յ�ϛ#w:݅�%��X�}�&�PSt�Q�"�-��\縵�/����$Ɨh�Xb�*�y��BS����;W�ջ_mc�����vt?2}1�;qS�d�d~u:2k5�2�R�~�z+|HE!)�Ǟl��7`��0�<�,�2*���Hl-��x�^����'_TV�gZA�'j� ^�2Ϊ��N7t�����?w�� �x1��f��Iz�C-Ȗ��K�^q�;���-W�DvT�7��8�Z�������� hK�(P:��Q- �8�n�Z���܃e貾�<�1�YT<�,�����"�6{/ �?�͟��|1�:�#g��W�>$����d��J��d�B��=��jf[��%rE^��il:��B���x���Sּ�1հ��,�=��*�7 fcG��#q� �eh?��2�7�����,�!7x��6�n�LC�4x��},Geǝ�tC.��vS �F�43��zz\��;QYC,6����~;RYS/6���|2���5���v��T��i����������mlv��������&� �nRh^ejR�LG�f���? �ۉҬܦƩ��|��Ȱ����>3����!v��i�ʯ�>�v��オ�X3e���_1z�Kȗ\<������!�8���V��]��?b�k41�Re��T�q��mz��TiOʦ�Z��Xq���L������q"+���2ۨ��8}�&N7XU7Ap�d�X��~�׿��&4e�o�F��� �H����O���č�c�� 懴�6���͉��+)��v;j��ݷ�� �UV�� i��� j���Y9GdÒJ1��詞�����V?h��l����l�cGs�ځ�������y�Ac�����\V3�? �� ܙg�>qH�S,�E�W�[�㺨�uch�⍸�O�}���a��>�q�6�n6����N6�q������N ! 1AQaq�0@����"2BRb�#Pr���3C`��Scst���$4D���%Td�� ?���N����a��3��m���C���w��������xA�m�q�m���m������$����4n淿t'��C"w��zU=D�\R+w�p+Y�T�&�պ@��ƃ��3ޯ?�Aﶂ��aŘ���@-�����Q�=���9D��ռ�ѻ@��M�V��P��܅�G5�f�Y<�u=,EC)�<�Fy'�"�&�չ�X~f��l�KԆV��?�� �W�N����=(� �;���{�r����ٌ�Y���h{�١������jW����P���Tc�����X�K�r��}���w�R��%��?���E��m�� �Y�q|����\lEE4���r���}�lsI�Y������f�$�=�d�yO����p�����yBj8jU�o�/�S��?�U��*������ˍ�0������u�q�m [�?f����a�� )Q�>����6#������� ?����0UQ����,IX���(6ڵ[�DI�MNލ�c&���υ�j\��X�R|,4��� j������T�hA�e��^���d���b<����n�� �즇�=!���3�^�`j�h�ȓr��jẕ�c�,ٞX����-����a�ﶔ���#�$��]w�O��Ӫ�1y%��L�Y<�wg#�ǝ�̗`�x�xa�t�w��»1���o7o5��>�m뭛C���Uƃߜ}�C���y1Xνm�F8�jI���]����H���ۺиE@I�i;r�8ӭ����V�F�Շ| ��&?�3|x�B�MuS�Ge�=Ӕ�#BE5G�����Y!z��_e��q�р/W>|-�Ci߇�t�1ޯќd�R3�u��g�=0 5��[?�#͏��q�cf���H��{ ?u�=?�?ǯ���}Z��z���hmΔ�BFTW�����<�q�(v� ��!��z���iW]*�J�V�z��gX֧A�q�&��/w���u�gYӘa���; �i=����g:��?2�dž6�ى�k�4�>�Pxs����}������G�9��3 ���)gG�R<>r h�$��'nc�h�P��Bj��J�ҧH� -��N1���N��?��~��}-q!=��_2hc�M��l�vY%UE�@|�v����M2�.Y[|y�"Eï��K�ZF,�ɯ?,q�?v�M 80jx�"�;�9vk�����+ ֧�� �ȺU��?�%�vcV��mA�6��Qg^M����A}�3�nl� QRN�l8�kkn�'�����(��M�7m9و�q���%ޟ���*h$Zk"��$�9��: �?U8�Sl��,,|ɒ��xH(ѷ����Gn�/Q�4�P��G�%��Ա8�N��!� �&�7�;���eKM7�4��9R/%����l�c>�x;������>��C�:�����t��h?aKX�bhe�ᜋ^�$�Iհ �hr7%F$�E��Fd���t��5���+�(M6�t����Ü�UU|zW�=a�Ts�Tg������dqP�Q����b'�m���1{|Y����X�N��b �P~��F^F:����k6�"�j!�� �I�r�`��1&�-$�Bevk:y���#yw��I0��x��=D�4��tU���P�ZH��ڠ底taP��6����b>�xa����Q�#� WeF��ŮNj�p�J* mQ�N����*I�-*�ȩ�F�g�3 �5��V�ʊ�ɮ�a��5F���O@{���NX��?����H�]3��1�Ri_u��������ѕ�� ����0��� F��~��:60�p�͈�S��qX#a�5>���`�o&+�<2�D����: �������ڝ�$�nP���*)�N�|y�Ej�F�5ټ�e���ihy�Z �>���k�bH�a�v��h�-#���!�Po=@k̆IEN��@��}Ll?j�O������߭�ʞ���Q|A07x���wt!xf���I2?Z��<ץ�T���cU�j��]��陎Ltl �}5�ϓ��$�,��O�mˊ�;�@O��jE��j(�ا,��LX���LO���Ц�90�O �.����a��nA���7������j4 ��W��_ٓ���zW�jcB������y՗+EM�)d���N�g6�y1_x��p�$Lv:��9�"z��p���ʙ$��^��JԼ*�ϭ����o���=x�Lj�6�J��u82�A�H�3$�ٕ@�=Vv�]�'�qEz�;I˼��)��=��ɯ���x �/�W(V���p�����$ �m�������u�����񶤑Oqˎ�T����r��㠚x�sr�GC��byp�G��1ߠ�w e�8�$⿄����/�M{*}��W�]˷.�CK\�ުx���/$�WPw���r� |i���&�}�{�X� �>��$-��l���?-z���g����lΆ���(F���h�vS*���b���߲ڡn,|)mrH[���a�3�ר�[1��3o_�U�3�TC�$��(�=�)0�kgP���� ��u�^=��4 �WYCҸ:��vQ�ר�X�à��tk�m,�t*��^�,�}D*� �"(�I��9R����>`�`��[~Q]�#af��i6l��8���6�:,s�s�N6�j"�A4���IuQ��6E,�GnH��zS�HO�uk�5$�I�4��ؤ�Q9�@��C����wp�BGv[]�u�Ov���0I4���\��y�����Q�Ѹ��~>Z��8�T��a��q�ޣ;z��a���/��S��I:�ܫ_�|������>=Z����8:�S��U�I�J��"IY���8%b8���H��:�QO�6�;7�I�S��J��ҌAά3��>c���E+&jf$eC+�z�;��V����� �r���ʺ������my�e���aQ�f&��6�ND��.:��NT�vm�<- u���ǝ\MvZY�N�NT��-A�>jr!S��n�O 1�3�Ns�%�3D@���`������ܟ 1�^c<���� �a�ɽ�̲�Xë#�w�|y�cW�=�9I*H8�p�^(4���՗�k��arOcW�tO�\�ƍR��8����'�K���I�Q�����?5�>[�}��yU�ײ -h��=��% q�ThG�2�)���"ו3]�!kB��*p�FDl�A���,�eEi�H�f�Ps�����5�H:�Փ~�H�0Dت�D�I����h�F3�������c��2���E��9�H��5�zԑ�ʚ�i�X�=:m�xg�hd(�v����׊�9iS��O��d@0ڽ���:�p�5�h-��t�&���X�q�ӕ,��ie�|���7A�2���O%P��E��htj��Y1��w�Ѓ!����  ���� ࢽ��My�7�\�a�@�ţ�J �4�Ȼ�F�@o�̒?4�wx��)��]�P��~�����u�����5�����7X ��9��^ܩ�U;Iꭆ 5 �������eK2�7(�{|��Y׎ �V��\"���Z�1� Z�����}��(�Ǝ"�1S���_�vE30>���p;� ΝD��%x�W�?W?v����o�^V�i�d��r[��/&>�~`�9Wh��y�;���R��� ;;ɮT��?����r$�g1�K����A��C��c��K��l:�'��3 c�ﳯ*"t8�~l��)���m��+U,z��`(�>yJ�?����h>��]��v��ЍG*�{`��;y]��I�T� ;c��NU�fo¾h���/$���|NS���1�S�"�H��V���T���4��uhǜ�]�v;���5�͠x��'C\�SBpl���h}�N����� A�Bx���%��ޭ�l��/����T��w�ʽ]D�=����K���ž�r㻠l4�S�O?=�k �M:� ��c�C�a�#ha���)�ѐxc�s���gP�iG��{+���x���Q���I= �� z��ԫ+ �8"�k�ñ�j=|����c ��y��CF��/��*9ж�h{ �?4�o� ��k�m�Q�N�x��;�Y��4膚�a�w?�6�>e]�����Q�r�:����g�,i"�����ԩA�*M�<�G��b�if��l^M��5� �Ҩ�{����6J��ZJ�����P�*�����Y���ݛu�_4�9�I8�7���������,^ToR���m4�H��?�N�S�ѕw��/S��甍�@�9H�S�T��t�ƻ���ʒU��*{Xs�@����f�����֒Li�K{H�w^���������Ϥm�tq���s� ���ք��f:��o~s��g�r��ט� �S�ѱC�e]�x���a��) ���(b-$(�j>�7q�B?ӕ�F��hV25r[7 Y� }L�R��}����*sg+��x�r�2�U=�*'WS��ZDW]�WǞ�<��叓���{�$�9Ou4��y�90-�1�'*D`�c�^o?(�9��u���ݐ��'PI&� f�Jݮ�������:wS����jfP1F:X �H�9dԯ���˝[�_54 �}*;@�ܨ�� ð�yn�T���?�ןd�#���4rG�ͨ��H�1�|-#���Mr�S3��G�3�����)�.᧏3v�z֑��r����$G"�`j �1t��x0<Ɔ�Wh6�y�6��,œ�Ga��gA����y��b��)��h�D��ß�_�m��ü �gG;��e�v��ݝ�nQ� ��C����-�*��o���y�a��M��I�>�<���]obD��"�:���G�A��-\%LT�8���c�)��+y76���o�Q�#*{�(F�⽕�y����=���rW�\p���۩�c���A���^e6��K������ʐ�cVf5$�'->���ՉN"���F�"�UQ@�f��Gb~��#�&�M=��8�ט�JNu9��D��[̤�s�o�~������ G��9T�tW^g5y$b��Y'��س�Ǵ�=��U-2 #�MC�t(�i� �lj�@Q 5�̣i�*�O����s�x�K�f��}\��M{E�V�{�υ��Ƈ�����);�H����I��fe�Lȣr�2��>��W�I�Ȃ6������i��k�� �5�YOxȺ����>��Y�f5'��|��H+��98pj�n�.O�y�������jY��~��i�w'������l�;�s�2��Y��:'lg�ꥴ)o#'Sa�a�K��Z� �m��}�`169�n���"���x��I ��*+� }F<��cГ���F�P�������ֹ*�PqX�x۩��,� ��N�� �4<-����%����:��7����W���u�`����� $�?�I��&����o��o��`v�>��P��"��l���4��5'�Z�gE���8���?��[�X�7(��.Q�-��*���ތL@̲����v��.5���[��=�t\+�CNܛ��,g�SQnH����}*F�G16���&:�t��4ُ"A��̣��$�b �|����#rs��a�����T�� ]�<�j��BS�('$�ɻ� �wP;�/�n��?�ݜ��x�F��yUn�~mL*-�������Xf�wd^�a�}��f�,=t�׵i�.2/wpN�Ep8�OР���•��R�FJ� 55TZ��T �ɭ�<��]��/�0�r�@�f��V��V����Nz�G��^���7hZi����k��3�,kN�e|�vg�1{9]_i��X5y7� 8e]�U����'�-2,���e"����]ot�I��Y_��n�(JҼ��1�O ]bXc���Nu�No��pS���Q_���_�?i�~�x h5d'�(qw52] ��'ޤ�q��o1�R!���`ywy�A4u���h<קy���\[~�4�\ X�Wt/� 6�����n�F�a8��f���z �3$�t(���q��q�x��^�XWeN'p<-v�!�{�(>ӽDP7��ո0�y)�e$ٕv�Ih'Q�EA�m*�H��RI��=:��� ���4牢) �%_iN�ݧ�l]� �Nt���G��H�L��� ɱ�g<���1V�,�J~�ٹ�"K��Q�� 9�HS�9�?@��k����r�;we݁�]I�!{ �@�G�[�"��`���J:�n]�{�cA�E����V��ʆ���#��U9�6����j�#Y�m\��q�e4h�B�7��C�������d<�?J����1g:ٳ���=Y���D�p�ц� ׈ǔ��1�]26؜oS�'��9�V�FVu�P�h�9�xc�oq�X��p�o�5��Ա5$�9W�V(�[Ak�aY錎qf;�'�[�|���b�6�Ck��)��#a#a˙��8���=äh�4��2��C��4tm^ �n'c���]GQ$[Wҿ��i���vN�{Fu ��1�gx��1┷���N�m��{j-,��x�� Ūm�ЧS�[�s���Gna���䑴�� x�p 8<������97�Q���ϴ�v�aϚG��Rt�Һ׈�f^\r��WH�JU�7Z���y)�vg=����n��4�_)y��D'y�6�]�c�5̪�\� �PF�k����&�c;��cq�$~T�7j ���nç]�<�g ":�to�t}�159�<�/�8������m�b�K#g'I'.W�����6��I/��>v��\�MN��g���m�A�yQL�4u�Lj�j9��#44�t��l^�}L����n��R��!��t��±]��r��h6ٍ>�yҏ�N��fU�� ���� Fm@�8}�/u��jb9������he:A�y�ծw��GpΧh�5����l}�3p468��)U��d��c����;Us/�֔�YX�1�O2��uq�s��`hwg�r~�{ R��mhN��؎*q 42�*th��>�#���E����#��Hv�O����q�}�����6�e��\�,Wk�#���X��b>��p}�դ��3���T5��†��6��[��@�P�y*n��|'f�֧>�lư΂�̺����SU�'*�q�p�_S�����M�� '��c�6�����m�� ySʨ;M��r���Ƌ�m�Kxo,���Gm�P��A�G�:��i��w�9�}M(�^�V��$ǒ�ѽ�9���|���� �a����J�SQ�a���r�B;����}���ٻ֢�2�%U���c�#�g���N�a�ݕ�'�v�[�OY'��3L�3�;,p�]@�S��{ls��X�'���c�jw�k'a�.��}�}&�� �dP�*�bK=ɍ!����;3n�gΊU�ߴmt�'*{,=SzfD� A��ko~�G�aoq�_mi}#�m�������P�Xhύ����mxǍ�΂���巿zf��Q���c���|kc�����?���W��Y�$���_Lv����l߶��c���`?����l�j�ݲˏ!V��6����U�Ђ(A���4y)H���p�Z_�x��>���e��R��$�/�`^'3qˏ�-&Q�=?��CFVR �D�fV�9��{�8g�������n�h�(P"��6�[�D���< E�����~0<@�`�G�6����Hг�cc�� �c�K.5��D��d�B���`?�XQ��2��ٿyqo&+�1^� DW�0�ꊩ���G�#��Q�nL3��c���������/��x ��1�1[y�x�პCW��C�c�UĨ80�m�e�4.{�m��u���I=��f�����0QRls9���f���������9���~f�����Ǩ��a�"@�8���ȁ�Q����#c�ic������G��$���G���r/$W�(��W���V�"��m�7�[m�A�m����bo��D� j����۳� l���^�k�h׽����� ��#� iXn�v��eT�k�a�^Y�4�BN��ĕ��0 !01@Q"2AaPq3BR������?���@4�Q�����T3,���㺠�W�[=JK�Ϟ���2�r^7��vc�:�9 �E�ߴ�w�S#d���Ix��u��:��Hp��9E!�� V 2;73|F��9Y���*ʬ�F��D����u&���y؟��^EA��A��(ɩ���^��GV:ݜDy�`��Jr29ܾ�㝉��[���E;Fzx��YG��U�e�Y�C���� ����v-tx����I�sם�Ę�q��Eb�+P\ :>�i�C'�;�����k|z�رn�y]�#ǿb��Q��������w�����(�r|ӹs��[�D��2v-%��@;�8<a���[\o[ϧw��I!��*0�krs)�[�J9^��ʜ��p1)� "��/_>��o��<1����A�E�y^�C��`�x1'ܣn�p��s`l���fQ��):�l����b>�Me�jH^?�kl3(�z:���1ŠK&?Q�~�{�ٺ�h�y���/�[��V�|6��}�KbX����mn[-��7�5q�94�������dm���c^���h� X��5��<�eޘ>G���-�}�دB�ޟ� ��|�rt�M��V+�]�c?�-#ڛ��^ǂ}���Lkr���O��u�>�-D�ry� D?:ޞ�U��ǜ�7�V��?瓮�"�#���r��չģVR;�n���/_� ؉v�ݶe5d�b9��/O��009�G���5n�W����JpA�*�r9�>�1��.[t���s�F���nQ� V 77R�]�ɫ8����_0<՜�IF�u(v��4��F�k�3��E)��N:��yڮe��P�`�1}�$WS��J�SQ�N�j�ٺ��޵�#l���ј(�5=��5�lǏmoW�v-�1����v,W�mn��߀$x�<����v�j(����c]��@#��1������Ǔ���o'��u+����;G�#�޸��v-lη��/(`i⣍Pm^���ԯ̾9Z��F��������n��1��� ��]�[��)�'������:�֪�W��FC����� �B9،!?���]��V��A�Վ�M��b�w��G F>_DȬ0¤�#�QR�[V��kz���m�w�"��9ZG�7'[��=�Q����j8R?�zf�\a�=��O�U����*oB�A�|G���2�54 �p��.w7� �� ��&������ξxGHp� B%��$g�����t�Џ򤵍z���HN�u�Я�-�'4��0��;_��3 !01"@AQa2Pq#3BR������?��ʩca��en��^��8���<�u#��m*08r��y�N"�<�Ѳ0��@\�p��� �����Kv�D��J8�Fҽ� �f�Y��-m�ybX�NP����}�!*8t(�OqѢ��Q�wW�K��ZD��Δ^e��!� ��B�K��p~�����e*l}z#9ң�k���q#�Ft�o��S�R����-�w�!�S���Ӥß|M�l޶V��!eˈ�8Y���c�ЮM2��tk���� ������J�fS����Ö*i/2�����n]�k�\���|4yX�8��U�P.���Ы[���l��@"�t�<������5�lF���vU�����W��W��;�b�cД^6[#7@vU�xgZv��F�6��Q,K�v��� �+Ъ��n��Ǣ��Ft���8��0��c�@�!�Zq s�v�t�;#](B��-�nῃ~���3g������5�J�%���O������n�kB�ĺ�.r��+���#�N$?�q�/�s�6��p��a����a��J/��M�8��6�ܰ"�*������ɗud"\w���aT(����[��F��U՛����RT�b���n�*��6���O��SJ�.�ij<�v�MT��R\c��5l�sZB>F��<7�;EA��{��E���Ö��1U/�#��d1�a�n.1ě����0�ʾR�h��|�R��Ao�3�m3 ��%�� ���28Q� ��y��φ���H�To�7�lW>����#i`�q���c����a��� �m,B�-j����݋�'mR1Ήt�>��V��p���s�0IbI�C.���1R�ea�����]H�6����������4B>��o��](��$B���m�����a�!=��?�B� K�Ǿ+�Ծ"�n���K��*��+��[T#�{E�J�S����Q�����s�5�:�U�\wĐ�f�3����܆&�)����I���Ԇw��E T�lrTf6Q|R�h:��[K�� �z��c֧�G�C��%\��_�a�84��HcO�bi��ؖV��7H �)*ģK~Xhչ0��4?�0��� �E<���}3���#���u�?�� ��|g�S�6ꊤ�|�I#Hڛ� �ա��w�X��9��7���Ŀ%�SL��y6č��|�F�a 8���b��$�sק�h���b9RAu7�˨p�Č�_\*w��묦��F ����4D~�f����|(�"m���NK��i�S�>�$d7SlA��/�²����SL��|6N�}���S�˯���g��]6��; �#�.��<���q'Q�1|KQ$�����񛩶"�$r�b:���N8�w@��8$�� �AjfG|~�9F ���Y��ʺ��Bwؒ������M:I岎�G��`s�YV5����6��A �b:�W���G�q%l�����F��H���7�������Fsv7��k�� 403WebShell
403Webshell
Server IP : 104.21.45.146  /  Your IP : 172.69.130.106
Web Server : Apache/2.4.52 (Ubuntu)
System : Linux ip-172-31-19-221 6.8.0-1029-aws #31~22.04.1-Ubuntu SMP Thu Apr 24 21:16:18 UTC 2025 x86_64
User : www-data ( 33)
PHP Version : 8.1.28
Disable Function : NONE
MySQL : OFF  |  cURL : ON  |  WGET : ON  |  Perl : ON  |  Python : OFF  |  Sudo : ON  |  Pkexec : ON
Directory :  /efsdata/scitechnol.com/httpdocs/submission/uploads/

Upload File :
current_dir [ Writeable ] document_root [ Writeable ]

 

Command :


[ Back ]     

Current File : /efsdata/scitechnol.com/httpdocs/submission/uploads/1827-1-Manuscript-2014-04-13.doc
��ࡱ�>��	������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������	��!�bjbj$$	8F|F|��-���������DDDDD����XXX8��LTXh2h�:��������1�1�1�1�1�1�1$�3��6X
2D�����
2DD���"2�#�#�#�D�D��1�#��1�#�#rW,T3-�������dW������ ��,�1820h2�,z�6�#F�63-�6D3-����#�����
2
2�#���h2�������������������������������������������������������������������������6���������� 
:	Late onset stress symptomatology, subclinical PTSD or mixed etiologies in previously symptom free aging combat veterans

Rajdip Barman, MD1, Mark B. Detweiler, MD, MS2,3,4
1Contributions while residents of the Carilion Clinic-University of Virginia Roanoke-Salem Psychiatric Medicine Residency, Salem, Virginia
2Geriatric Research Group, Salem Veterans Affairs Medical Center, Salem, Virginia
3Staff Psychiatrist, Salem Veterans Affairs Medical Center, Salem,  Virginia 
4Virginia Tech-Carilion School of Medicine Department of  Psychiatry and Behavioral Medicine, Roanoke, Virginia
Correspondence to: Mark B. Detweiler, MD, Mental Health Service Line (116A7), Veterans Affairs Medical Center, 1970 Roanoke Boulevard, Salem, Virginia, 24153, USA. Phone 540-982-2463 extension 1652.  FAX 540-983-1080. E-mail   HYPERLINK "mailto:mark.detweiler1@va.gov" mark.detweiler1@va.gov
The authors report no conflict of interest. The report findings do not represent the views of the Department of Veterans Affairs or the United States Government. This material is the result of work supported with resources and the use of facilities at the Salem, Virginia Veterans Affairs Medical Center.
Abstract
The reaction to combat stress is variable and complicated. When elderly combat veterans with no prior history of PTSD present to the Emergency Department (ED) with PTSD-like symptoms, the differential diagnosis can be perplexing. The case may be cofounded by multiple medical problems and early neurocognitive degeneration problems. A new diagnostic phenomena is late-onset stress symptomatology (LOSS) needs to be considered in late onset first time presentation of PTSD-like symptoms. It is a clinical phenomenon reported in aging combat veterans who have experienced stressful combat events in their early adult years followed by a successful post-military life. It is considered a late life normative processing of the memories from the veteran�s combat experiences, especially following retirement.  It is prudent to understand complex interconnectedness of each veteran�s biopsychosocial history to assist in establishing the proper diagnosis and the degree of acute and chronic combat stress response in the ED presentation. The case report illustrates some of the clinical diagnostic conundrums that our aging combat veterans present in EDs and outpatient clinics, particularly in the Veterans Affairs hospitals and community based outpatient clinic primary care and mental health services.

Key words: Late-onset stress symptomatology, PTSD, Stress, Dementia, Mild Cognitive Impairment, Aging.
Introduction
Stress is an inevitable, and in some cases a desirable, occurrence of everyday [1]. Traumatic stress is defined in DSM-V as �exposure to actual or threatened death, serious injury, or sexual violence�. Combat may be catastrophic and horrifying, resulting in serious psychological and functional disruption [2]. Combat stress is the reaction wartime experiences that usually recede with the passage of time. It is noted that the continual processing of combat experiences and memories, most appropriately with members of the combat unit and involvement with other veterans, is helpful in allowing the soldier and veteran to move into successive phases of their lives without difficulty [3,4]. Recent studies have identified a cohort of combat veterans that does not develop subthreshold PTSD and full PTSD, but may experience increasing reminisces of their combat experiences later in life without any disruption or social or vocational affairs. This clinical presentation is called late onset stress symptomatology (LOSS) [5,6].
The demographics of PTSD indicate differences according to age, gender and military exposure.  Understanding the influence of combat stress in aging veterans is important as approximately 40 percent of veterans are 65 years or older [7].  PTSD in less prevalent among elderly than younger adults [8-10].  Approximately 70 to 90 percent of adults aged 65 and over, have been exposed to at least one potentially traumatic event [11]. However, the lifetime prevalence of PTSD for adults over 60 years of age is estimated to be eight percent [12,13]. Estimates of PTSD among military personnel vary from 2 to 17 percent [14]. Males have an increased prevalence of PTSD compared to females (1.7:1) most probably relating to greater exposure to military combat [2,15]. Sub-threshold levels of PTSD have been estimated to range from seven to 28.5 percent in the general population [16-18]. 
What is LOSS in aging combat veterans?

LOSS is a clinical phenomenon reported in aging combat veterans who have experienced traumatic events during their military service. It is considered a late life normative processing of the combat memories, especially following retirement [5,6]. Veterans that develop LOSS usually have had successful cognitive and functional lives without a history of additional trauma or chronic stress related disorders. Combat veterans presenting with LOSS most frequently complain of increased positive combat-related reminisces following 30 to 50 years of infrequent past combat memories. In LOSS, the symptoms do not disruptive cognitive or functional stability [6]. These veterans do not experience hyper arousal symptoms or sleep disturbances. The combat memories in LOSS are principally positive and increase in frequency decades after the onset in contrast to the early onset of negative combat memories in veterans with PTSD. In aging combat WW II, Korean and Vietnam veterans, the clinician needs to differentiate LOSS from other stress related disorders such as subthreshold PTSD (classified as �undifferentiated stress related disorder� in DSM V), full PTSD (classified as a �Trauma and Stressor-Related Disorder� in DSM V), depression, anxiety disorders and declining cognition [6, 19-21].
Potential biologic correlates of LOSS and other stress reactions.

	There are many factors that may contribute to the development of the stress spectrum symptoms that encompass LOSS to PTSD.  Genetic studies have shown that monozygotic twins had a higher concordance rate than dizygotic twins for experiencing trauma, specifically exposure to combat [22,23]. Utilizing diffusion tensor imaging (DTI) to measure white matter integrity in PTSD, Fani et al. [24] found that persons who do not experience PTSD have more robust cingulate bundles connecting the prefrontal cortex and the hippocampus enabling a more modulated emotional reaction to stress [25]. Consequently, when there is reduced microarchitectural integrity of the cingulum there may be an inadequate extinction of learned fear, with compromised attention memory functions [24]. Thus, it may be that the soldiers and veterans with a LOSS response to combat stress have more intact cingulate bundles compared to individuals with less robust cingulate bundles. 
The nature and type of the trauma, proximity and the level of social support are significant social factors in PTSD susceptibility.  The Two-Factor Theory of classical conditioning postulates that the development of fears when the terror inherent in the trauma is paired with the cues associated with the traumatic event. In contrast, Operant Conditioning maintains that an individual�s behavior is modified by its consequences. Therefore, post combat positive and/or negative experiences may change combat stress in form, frequency, or strength [26,27] .  
There have been extensive studies about the consequences of military combat among soldiers. Authors report a strong correlation between a soldier�s premilitary biopsychosocial experiences and their post combat psychosocial evolution [28-31].  Recently, many soldiers have been found to have psychiatric problems prior to deployment [31,32]. Kessler et al.[32] reported that 25 percent of active duty, non-deployed Army soldiers tested positive for at least one psychiatric disorder and 11 percent demonstrated signs of more than one psychiatric disorder.  In many cases, these psychiatric problems (e.g., major depression, anxiety disorders including panic disorder and PTSD) were present prior to enlistment. For example, about 60 percent soldiers who had attempted suicide had mental disorders that appeared to have begun prior to enlistment in the military [21,33,34].  Approximately 13 percent of the soldiers were found to have mental health impairments that could compromise their military duties during or outside of combat activities.  Nock et al. [31] found that about 14 percent of soldiers said they had had suicidal thoughts, 5.3 percent had planned suicide and 2.4 percent had made actual attempts. This population of soldiers that had a history of psychiatric diagnoses pre-, during and after military discharge would probably include the cohort  most prone to develop subthreshold PTSD and PTSD during or following combat [33,34].  The corollary of these findings is that the combat veterans, without a history of biopsychosocial risk factors pre- and during military service, would have a lower probability of experiencing disruptive psychiatric conditions during or following combat experiences.  Those veterans presently with LOSS symptoms would be expected to have no or mild post combat psychosocial long term sequalae.  Following discharge, this combat cohort would have a higher probability of experiencing a successful and stable life when compared to combat veterans with pre-enlistment biopsychosocial stress risk factors [6,24,25].

How do subthreshold PTSD and full PTSD differ from LOSS 
	Many older combat veterans  enjoy well-being and satisfaction in later years while others may experience a continuum of psychiatric and mental health difficulties ranging from very mild to severe and debilitating [35]. During recent years, mental health professionals, especially the Department of Veterans Affairs clinicians, have been reporting the late life onset or PTSD-like symptoms in aging combat veterans [36-38]. These symptoms frequently coincide with normative aging life events and are not necessarily associated with social and occupational disturbances. Based on existing literature, it can be hypothesized that there is a continuum of response to military combat experiences based a variety of variables [6,21]. Some of the variables associated with post combat functional and psychiatric changes  include: diagnosed or undiagnosed history of psychiatric diagnoses pre- and during military service [31,32];  failure with aging of compensatory avoidance-based coping strategies in early and mid-life (e.g., alcohol, street drugs,  over working) [35]; retirement [39]; increased medical and psychiatric problems  [9,39,40];  reduced income; loss of partner and friends; isolation and decreased social support [41];  and prolonged PTSD associated with accelerated brain aging and dementia [21,34].
The discriminant validity between LOSS and PTSD has been studied by Potter et al. [6].  The associations of LOSS and PTSD with other psychological variables were examined in a sample of 562 older male combat veterans that completed both the LOSS Scale and the PTSD Checklist � Civilian Version. Potter et al. [6] found a curvilinear relationship with PTSD with the positive curvilinear association between LOSS and PTSD diminishing at higher levels of PTSD. Results demonstrated that LOSS was associated more with worries about retirement. In contrast, PTSD was more associated with: depression; anxiety; reduced sense of mastery; and decreased satisfaction with life [6].  The core aspects of PTSD such as re-experiencing (flashbacks), avoidance, emotional numbing and hyperarousal are absent in veterans with LOSS [5].  The predominant features of LOSS are that it is considered a normal ageing process in the aging combat veteran that presents as late onset of reminiscences or positive memories of combat experiences that are not necessarily intrusive.  Therefore, LOSS is conceptually and statistically more strongly associated with normative late-life passages than are subthreshold PTSD than to PTSD [6]. The reaction to combat stress may be viewed as varying along a continuum often beginning during combat [42]: no long term negative symptoms with extinction of learned fear with intact attention memory functions; mild non-disruptive symptoms associated with normal aging; disruptive symptoms associated with subthreshold PTSD; and, full PTSD. While the diagnoses of subthreshold and full criteria PTSD can be compounded by other trauma related diagnoses such as other major depression, panic disorder, borderline personality disorder and substance  disorders  [43-45] , combat veterans with LOSS usually do not have comorbid disruptive psychiatric problems [6]. However, LOSS may begin to interfere with function and cognition if it evolves into subthreshold PTSD, PTSD, other anxiety disorders, depression or paranoia [6]
As LOSS is thought to be a normal aging phenomenon without any symptoms of subthreshold PTSD or full PTSD, the question arises, what is the threshold between LOSS and subthreshold PTSD?  The percentage of older adults with sub-clinical levels of PTSD symptoms ranges from 7% to 15% [39,46,47]. It is not known what percentage of combat veterans in these subthreshold PTSD might have LOSS as this concept is new to clinicians.  Some of the veterans with LOSS may be included in the present estimates of subthreshold PTSD prevalence in the same manner that Peterson found cases of mild cognitive impairment when he reexamined his normative aging cognitive indices [48].
Are there links between combat stress and cognitive deficits? 

Several studies in the elderly link chronic stress to cognitive decline, functional impairment and dementia [19,20]. It is known that persons with PTSD have multiple risk factors that may precipitate dementia The cognition impairing neuroendocrine alterations involving changes in the hypothalamic-pituitary-adrenal axis and pro-inflammatory cytokines associated with chronic stress, such as PTSD, have been described [49-52]. For combat veterans in general, the contribution of ongoing degenerative neurocognitive processes from combat stress must be considered [6,7]. Individuals diagnosed with PTSD were almost twice as likely to develop dementia, when compared to those without PTSD [21].  Also, veterans with PTSD perform more poorly than controls on cognitive tests [19,20].  The question arises as to whether there is a greater risk of earlier onset of cognitive deficits among combat veterans with LOSS compared to cohorts with subthreshold PTSD, PTSD or  without combat stress, has not been addressed at this time.  
With the aging of the US combat veteran population, it is important to understand the nuisances in the differential diagnosis when confronted with changes in mental status accompanied by symptom of LOSS, subthreshold PTSD or PTSD in veterans presenting with late onset PTSD-like symptoms.  This case report illustrates some of the clinical questions that will become routine diagnostic conundrums in many outpatient clinics, particularly the Veterans Affairs (VA) primary care and mental health offices for the combat veterans over 60 years of age.
Case Report

An 83 year old African American Korean War veteran came to the Emergency Department (ED) complaining of combat related nightmares and memory problems.  The veteran was accompanied by his neighbor as the veteran was principally wheelchair bound due to chronic pain, status post back surgeries with bilateral leg weakness. His nightmares had begun about 3 years prior and involved killing people and seeing dead bodies. The nightmares had been increasing in frequency during the last several months. The veteran had noticed memory deficits for the last 2-3 years that primarily involving his recent memory.  Sleep duration had decreased to about 4 hours a night, interrupted by nightmares. Viewing combat related news on the television was identified as an external trigger for nightmares. He reported feelings of internal discomfort, thoughts about past combat experiences, and feelings of shame and guilt regarding participating in combat activities. However, he denied any symptoms suggestive of flashbacks or hyperarousal. On interview, the veteran did not want to talk about his combat experiences. He was most concerned with his increasing nightmares. The veteran hypothesized that the nightmares were triggering memories of his wartime experiences and thus contributing to his feelings of shame and guilt.
The veteran denied any recent changes in behavior with no symptoms of agoraphobia, avoidance, irritability or aggression. He denied depressed mood, crying episodes, feelings of hopelessness, helplessness and worthlessness.  His appetite was described as �good� with no recent weight changes.  The veteran was living independently and caring for his wife who had dementia in addition to multiple medical problems.  His wife�s health had deteriorated during the last 5 to 6 years.  While the veteran was not able to drive an automobile due to his physical disabilities, he was managing his financial affairs, cooking, and reading. He denied having difficulties with his other independent activities of daily living.  There was no personal history of psychiatric illness, illicit drug, tobacco or alcohol use.  His past medical history was significant for hyperlipidemia, hypertension, and multiple back surgeries.
The veteran�s family history revealed that the veteran�s mother died of dementia in her eighties.  The legal history was noncontributory.  The couple has one child who lives in Florida and thus he is unable to help the veteran with daily caregiver or household duties.  After serving in the Korean War as an infantry man, the veteran was discharged from the US Army in the mid-1950s. He retired from work in 1999. 
The veteran has significant present life stressors including his physical disability, social isolation and being a single 24-hour a day caregiver for his wife. .   He essentially has had minimal help with care for his wife, except for his one friend who runs errands and drives the couple to their respective medical appointments. The veteran does all the household chores despite his physical disabilities. 
The mental status examination revealed the veteran to be alert, looking his stated age, with good hygiene and sitting in a wheel chair. He was oriented to person, place situation and date. There was mild psychomotor agitation, although he maintained good eye to eye contact.  The veteran was cooperative and pleasant. Speech had normal volume, rate and prosody. There was no latency or word finding difficulty. Mood was defined as �fine� and the veteran�s affect was dysthymic and anxious.  There were no observed involuntary movements.  Thought processes were linear, logical and goal directed. Thought content was devoid of suicidal and homicidal ideations, plan or intent, without obsessions, compulsions, hallucinosis, loosening of association or flight of ideas.  Judgment was fair and insight was good. Concentration was well sustained. The Montreal Cognitive Assessment (MOCA) demonstrated a score of less than 26 suggesting mild neurocognitive decline.  Deficits were registered in: recent memory; visuo-spatial functioning; recall; and subtraction.  The 4-point clock test did not demonstrate deficits. The LOSS scale score [6] was significant and relatively higher than the PTSD Checklist-Military (PCL-M) score.
Review of symptoms showed stable vital signs with nocturia, increased urination frequency, back pain, bilateral decreased muscle strength (4/5), with tingling and numbness in both lower extremities. Laboratory tests were all normal including complete blood count, basic metabolic panel, urine analysis, B12, folic acid, thyroid stimulating hormone (3.505), urine drug screen and rapid plasma regain test. The head CT was negative for atrophy and acute changes. Scheduled medications were:  amlodipine 10 mg in the morning (x 10 years); hydrochlorothiazide 20 mg daily (x 10 years); hydralazine 10 mg twice a day (x 3 years); fish oil 1000 mg (x 2 years);  and atorvastatin 10 mg nightly (x 10 years).
At this point the differential diagnosis included:  1) subthreshold PTSD (undifferentiated stress related disorder); 2) LOSS); 3) mild neurodegenerative disease; 4) mild depressive symptoms; and 5) medication induced nightmares;
Discussion

	Researchers at the Boston VA suggest that LOSS may be a component of subthreshold PTSD [6]. However, as LOSS is not associated with functional or cognitive disruptions following military discharge, it appears to be a normative aging adjustment which excludes subthreshold PTSD. Following the hypothesis of a continuum of stress response in combat veterans, it is probable that as the severity of LOSS symptoms increase, the diagnosis would cross over the threshold from LOSS to mild subthreshold PTSD.  
It may be speculated that there is a graded response to combat stress based on the interplay of premilitary biopsychosocial factors with the severity and duration of combat exposure [22-24,31,50-61]. Based in existing literature, it can be hypothesized that there is a 4-stage continuum of response to military combat stress experiences based on multiple variables. Stages one would include normal daily function since military discharge without occupational or social difficulties. In stage two (LOSS) elderly combat veterans would have increased combat reminiscences, still without occupational or social difficulties [6,35];   Mild to severe subthreshold PTSD symptoms that reduce the veterans� quality of life would appear in stage three. In stage four (PTSD), the most severe occupational and social disruption would be observed. It has been reported that the fewer criteria of subthreshold PTSD may be as life altering as the more numerous criteria of full PTSD [62]. 
In clinic practice, the finding of LOSS should be more prevalent in the medical clinics than mental health clinics as the majorly of veterans with LOSS do not meet criteria of subthreshold or full PTSD. Consequently, they usually do not need the services of mental health providers.  In a study of 1,300 patients with trauma, [62] found that 12 percent met criteria for full PTSD and seven percent for subthreshold PTSD.  Notably, the majority of persons with trauma history (35.4%) had no PTSD-related symptoms.  

Why would a combat veteran have LOSS symptoms at age 83?

This case study presents several questions.  First, why would an 83 year old combat veteran have his first disruptive symptoms associated with combat at age 83? As for aging noncombat veterans and combat veterans, experience feelings of lost  power, autonomy and control that recapitulate memories and feelings related to life earlier stressors and/or losses [63]. These memories and feelings do not necessarily impair functioning. In this case, the veteran was having both distressing combat nightmares and memory difficulties that precipitated his trip to the ER. 

LOSS and Subthreshold PTSD
The second question is why would the nightmares of subclinical PTSD would first appear during the eight decade of life?  Most symptoms subthreshold occur within six months of exposure to the combat events according to DSM-V criteria. Delayed-onset PTSD with no prior history of PTSD symptoms is uncommon [64].  In military cases of delayed onset PTSD symptoms, 38.2% of the cases could be accounted for by an exacerbation of previously recorded symptoms [65]. The 83 year old combat veteran in this case does meet criteria for subthreshold PTSD as he presented with disruptive nightmares. Combat dreams that did not reduce his quality of life would be more supportive of a LOSS diagnosis.  
				
Why is mild neurodegenerative disease such as MCI or early dementia important when considering LOSS or subclinical PTSD?
The third diagnostic question in this case is why would there be a heightened risk of concurrent neurodegenerative disease such as MCI or early dementia in the case of LOSS or subthreshold PTSD? Could an underlying neurodegenerative process be contributing to the nightmares? The MOCA results suggest that the 83 year old combat veteran has some ongoing mild neurocognitive degenerative processes based on his age [66,67], combat exposure [68], hyperlipidemia [69], hypertension [70,71] and post-surgery anesthesia consequences [72].   


What is the origin of the combat nightmares?
The fourth question involves the relationship between combat stress and the veteran�s combat nightmares. A literature base affirming that the nightmares and neurodegenerative processes are interconnected was found to be speculative [73]. Rather, the literature reveals that many of the nightmares associated with neurocognitive decline are principally medication induced.  The most frequently cited drugs are acetyl cholinesterase inhibitors [74,75] which were not being prescribed in this case. Considering all possible sources of the nightmares, it was concluded that the most probable source was increased memories of combat, triggered by the media coverage of worldwide violence (e.g., Iraq, Afghanistan, Libya, Syria, Pakistan, Egypt) that the veteran admitted watching on TV.
The relationship between symptoms recorded in veterans with LOSS or subthreshold PTSD become more difficult to individuate when concurrent with combat stress related neurodegenerative disease, multiple medical problems and individual psychosocial risk factors.  It is reported that combat and noncombat risk factors may accelerate neurodegenerative processes [20,31,33,35,49,53,54,58,76-78].  Thus, in the older combat veteran cohorts presenting in clinic with new onset cognitive and functional changes, the diagnosis may be confounded by signs and symptoms from degenerative disease progression, LOSS and subthreshold PTSD [76,78-80].
Recent studies emphasize that biopsychosocial events may have a significant negative impact on military personnel.  Approximately 13 percent of present day soldiers were found to have mental health impairments that could compromise their military duties Nock et al. [31] found that about 14 percent of soldiers said they had had suicidal thoughts, 5.3 percent had planned suicide and 2.4 percent had made actual suicide attempts. It could be speculated that his this population of soldiers that have a history of psychiatric diagnoses pre-, during and after military discharge would have an increased risk of subthreshold PTSD and PTSD compared to the cohort without biopsychosocial events. 
The combat veterans with a negative pre-military biopsychosocial events may have a greater risk of early onset cognitive deficits due to chronic stress [21,33,34].  The interrelationship of psychological stress, PTSD and dementia has been reported in a large study of veterans with and without PTSD.  PTSD was been found to be a significant contributor to the earlier onset of cognitive deficits due to ongoing psychological stress dementia [21,33,34].  Yaffe et al [21] reported that the veterans diagnosed with PTSD had an approximate 2-fold-higher risk of developing dementia compared with veterans without PTSD.  With the hypothesis that there is a gradated neurodegenerative response to combat stress, it would appear prudent to rule out a concurrent neurodegenerative processes in combat veterans presenting with LOSS and subthreshold PTSD.  
What are the biological consequences of combat stress experiences and PTSD?  In general, the main components of the stress response are the hypothalamic-pituitary-adrenal (HPA) axis, the limbic cortex and the immunological systems.  Selected areas of the brain are activated during PTSD in response to PTSD related stimuli [50,54]. The brain areas thought to be the most important in PTSD are the hippocampus, amygdala, and medial prefrontal cortex [58]. In several neuroimaging studies, PTSD patients were found to have increased function in posterior cingulate, motor cortex [56] and amygdala [60]. There was also decreased prefrontal, parietal, hippocampal and temporal cortical function [55-57,61]. The PTSD patients had increased left amygdala activation with fear acquisition, and decreased anterior cingulate function during extinction, relative to controls [59].  These studies suggest that combat stress results in structural and functional changes in these critical brain areas will have long term cognitive and functional consequences for combat veterans related to the number and severity of the biopsychosocial life variables pre-, during and post military service.  
Regarding the neuroendocrine reaction to acute and prolonged stress, there is an increase in cortisol levels.  These endocrine changes contribute to chronic stress-allostatic down regulation of the glucocorticoid system that may facilitate chronic inflammation. The chronic stress cascade continues with increased levels of cytokines, enhanced cellular immune responses and increased levels of C-reactive protein [81].  Specifically, acute and chronic results of combat stress may damage hippocampal function with decreased volume and decreased N-Acetyl Aspartate [51]. These changes may compromise learning in addition to degrading short term and remote memory [51,82] . The combat veterans who have a normative or LOSS response to their combat experiences would most likely have had a lower cumulative level of stress, less severe neuroendocrine degradation and a later onset of cognitive decline than those veterans with subthreshold PTSD or full PTSD. Although the 83 year old veteran that came to the ER was independently caring for his demented wife and proficient in his IADLs, the veteran complained of memory deficits and his MOCA score was below normal suggesting mild neurocognitive decline. The specific contributions of the medical (hyperlipidemia, hypertension, multiple back surgeries, post-surgery amnesia [69-72] and combat stress for this veterans cognitive deficits are unclear.   


Were depressive symptoms involved in the veteran�s symptoms? 
	
The 83 year old Korean War combat veteran presenting in the ER is in the last of Ericson�s eight life stages, Ego Integrity vs. Despair (ages 65 years to death).  He has no prior psychiatric history. Despite his combat experiences he has had a successful career and marriage. His case is complicate by being a single caregiver and having to do his daily activities and care of his wife from a wheel chair. Therefore, we considered �care giver stress syndrome [83] as a factor that may be causing depressive symptoms. Although he has chronic somatic (wheelchair bound, chronic back, leg pain) and social (single care giver for his wife with dementia) stressors, the symptoms that the veteran reported seeking help for were the worsening of combat nightmares and memory deficits.  As the veteran denied any depressive symptoms and his brief depression screen was negative, depressive symptoms were ruled out.   

Medication induced nightmares versus other origins: Is there any relationship between neurocognitive degenerative disease and nightmares?  

The original hypothesis was that the veterans� nightmares were medication induced. Both psychiatric and non-psychiatric medications may induce nightmares either singularly or in combination [84]. In this case report, the veteran�s nightmares commenced about three years prior to his ER visit. He has five prescribed medications that have been associated with nightmares.  Amlodipine [85], hydrochlorothiazide [86], and atorvastatin [87], had been prescribed for 10 years or more. Hydralazine [88], and fish oil had been added to the veteran�s medication profile during the last three and two years respectively, thus approximating the reported duration of the nightmare episodes. Given the temporal relationship of the medication-nightmare history, it is doubtful that amlodipine, hydrochlorothiazide and atorvastatin were contributing factors.  However, it cannot be ruled out that the hydralazine and fish oil, either singularly or in combination with the other four potential precipitators of nightmares, may have been contributed to the veteran�s combat nightmares.  

Case Resolution

With the above background information, the differential diagnosis can be reexamined to include the following rule out diagnoses:  
1)	Undifferentiated stress related disorder (subthreshold PTSD) 
2)	Rule out mild neurodegenerative disorder.
3)   Rule out medication induced nightmare disorder.

Conclusions

This case illustrates several diagnostic questions about the long term consequences of combat stress in veterans that have had successful lives, without psychological symptoms for decades after their military service, who then develop non-disruptive or mild PTSD-like symptoms in their sixth and seventh decades. The analysis of this veteran�s symptoms when he presented to the ER and afterward on testing in the mental health clinic is strongly supportive of the diagnosis of very mild subclinical PTSD with an underlying mild neurodegenerative process.  The veteran had no significant biopsychosocial stressors in his life other than his combat experiences.  Similar cohorts may experience the LOSS phenomenon in their elderly years.  LOSS had to be ruled out as the veteran had neither signs of subthreshold or full PTSD until he was eighty years old. It is difficult to ascertain whether the combat nightmares and cognitive decline were more related to combat stress, medications and/or neurodegenerative processes. 
The case reveals that there is more to understand about our aging combat veterans� biopsychosocial evolution with age. It also suggests that improved screening of new military recruits may improve differentiating those who are more suited for combat experience.  Those recruits with predisposing biopsychosocial risk factors for subthreshold and full PTSD could be directed to non-combat military occupational specialties. In the short term, such a system would assist in promoting a more effective military. In the long term, such an advanced selection system may reduce acute and chronic reactions to combat stress. A reduction of subthreshold and full PTSD symptoms might significantly reduce the number of service connection disability payments for combat soldiers with PTSD and other combat related stress diagnoses. Research into the predisposing factors and diagnosis of individual risk for the spectrum of consequences from combat stress, including LOSS, subthreshold and full PTSD could better determine what resources are needed for maximize military personnel performance and reduce the acute and chronic pathological results from combat stress during and after military discharge. 

References

Chrousos GP (2009) Stress and disorders of the stress system. Nature Reviews. Endocrinology 5: 374�381.
Sargent PD, Campbell JS, Richter KE, McLay RN, Robert L, et al. (2013) Integrative Medical Practices for Combat-Related Posttraumatic Stress Disorder.  Psychiatric Annals 43: 181-187.
Perkonigg A, Pfister H, Stein MB, H�fler M, Lieb R, et al. (2005) Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. Am J Psychiatry 162: 1320-1327.
Kennedy C. Combat Stress Versus Posttraumatic Stress Disorder. http://www.brainlinemilitary.org/content/2013/10/combat-stress-versus-post-traumatic-stress-disorder.html. Accessed April 3, 2014
Davison EH, Pless AP, Gugliucci MR, King LA, King DW, et al. (2006) Late life emergence of early life trauma: The phenomenon of late-onset stress symptomatology among aging combat veterans. Research on Aging 28: 84�114.
Potter CM, Kaiser AP, King LA, King DW, Davison EH, et al. (2013) Distinguishing late-onset stress symptomatology from posttraumatic stress disorder in older combat veterans. Aging Ment Heal 17: 173-179.
Chatterjee S, Spiro A, King L, King D, Davison E (2009) Research on aging military veterans: Lifespan implications of military service. PTSD Research Quarterly 20: 1-7.
Averill PM, Beck JG (2000) Posttraumatic stress disorder in older adults: A conceptual review. Journal of Anxiety Disorders 14: 133-156.
Durai UNB, Chopra MP, Coakley E, Llorente MD, Kirchner JE, et al. (2011)  Exposure to trauma and posttraumatic stress disorder symptoms in older Veterans attending primary care: Comorbid conditions and self-rated health status. Journal of the American Geriatric Society 59: 1087-1092.
Pietrzak R H, Goldstein RB, Southwick SM, Grant BF (2012) Psychiatric comorbidity of full and partial posttraumatic stress disorder among older adults in the United States: Results from wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. American Journal of Geriatric Psychiatry 20: 380-390.
Norris FH (1992) Epidemiology of trauma: Frequency and impact of different potentially traumatic events on different demographic groups. Journal of Consulting and Clinical Psychology 60: 409-418.
Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62: 617-627.
Acierno R, Lawyer SR, Rheingold A, Kilpatrick DG, Resnick HS, et al. (2007) Current psychopathology in previously assaulted older adults. Journal of Interpersonal Violence 22: 250-258.
Richardson L, Frueh C, Acierno R (2010) Prevalence estimates of combat-related post-traumatic stress disorder: Critical review. Australian and New Zealand Journal of Psychiatry 44: 4-19.
Creamer MC, Parslow RA (2008) Trauma exposure and posttraumatic stress disorder in the elderly: A community prevalence study. American Journal of Geriatric Psychiatry 16: 853-856.
Marshall RD,  Olfson M, Hellman F, Blanco C, Guardino M, et al. (2001) Comorbidity, impairment and suicidality in subthreshold PTSD. American Journal of Psychiatry 158: 1467�1473.
Carlier IVE, Lamberts RD, Fouwels AJ, Gersons BPR (1996) PTSD in relation to dissociation in traumatized police officers. American Journal of Psychiatry 153: 1325�1328.
Blanchard EB, Hickling EJ, Barton KA, Taylor AE, Loos WR, et al. (1996)  One year prospective follow-up of motor vehicle accident victims. Behavioral Research on Therapy 34: 775�786.
 KW, Neylan TC, Metzler TJ, Rothlind J, Henn , et al. (2006) Neuropsychological functioning in posttraumatic stress disorder and alcohol abuse. Neuropsychology 20: 716-726.
Yehuda R, Tischler L, Golier JA, Grossman R, Brand SR, et al. (2006). Longitudinal assessment of cognitive performance in Holocaust survivors with and without PTSD. Biol Psychiatry 60: 714-721.
Yaffe L, Vittinghoff E, Lindquist K, Barnes D, E Covinsky KE, et al. (2010) Post-Traumatic Stress Disorder and Risk of Dementia among U.S. Veterans.  Arch Gen Psychiatry 67: 608�613.
True WJ, Rice J, Eisen SA, Heath AC, Goldberg J, et al. (1993) A twin study of genetic and environmental contributions to liability for posttraumatic stress symptoms. Archives of General Psychiatry 50: 257-264.
Stein MB, Jang KL, Taylor S, Vernon PA, Livesley WJ (2002) Genetic and environmental influences on trauma exposure and posttraumatic stress disorder symptoms: A twin study. American Journal of Psychiatry 159: 1675-1681.
Fani N1, King TZ, Jovanovic T, Glover EM, Bradley B, et al. (2012) White matter integrity in highly traumatized adults with and without post-traumatic stress disorder. Neuropsychopharmacology 37: 2740-2746.
Iarovici D (2013) Resilience in psychiatry. Psychiatric Annals 43: 530-532.
Skinner  BF (1950) Are theories of learning necessary?  Psychological Review 57: 193-216.
Keane T M, Zimering RT, Caddell RT (1985) A behavioral formulation of PTSD in Vietnam Veterans. Behavior Therapist 8: 9�12.
Elder GH, Clipp EC (1989). Combat experience and emotional health: Impairment and resilience in later life. Journal of Personality 57: 311�341.
Elder GH, Shanahan MJ, Clipp EC (1994) When war comes to men�s lives: Life-course patterns in family, work, and health. Psychology and Aging 9: 5�16.
King LA, King DW, Vickers K, Davison EH, Spiro A III (2007) Assessing late-onset stress symptomatology among aging male combat veterans. Aging Ment Healt 11: 175-179.
Nock MK, Stein MB, Heeringa SG, Robert J, Ursano RJ, et al (2014). Prevalence and Correlates of Suicidal Behavior among Soldiers: Results from the Army Study to Assess Risk and Resilience in Service Members (Army STARRS). On line publishing March 03.
Kessler RC, Heeringa SG, Stein MB, Colpe LJ, Fullerton CS, et al. (2014) Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army: Results from the Army Study to Assess Risk and Resilience in Service Members (Army STARRS). On line publishing March 03.
Yehuda R (2002) Post-traumatic stress disorder. N Engl J Med 2: 108�114.
Herbert J, Goodyer IM, Grossman AB, Hastings MH, De Kloet ER, et al (2006). Do corticosteroids damage the brain? Journal of Neuroendocrinology 18: 393�411.
Kaiser AP, Wachen JS,  Potter C,  Jennifer MJ,  Davison E, et al (2014) Posttraumatic Stress Symptoms among Older Adults: A Review (with the Stress, Health, and Aging Research Program (SHARP).  PTSD: National Center for PTSD.  http://www.ptsd.va.gov/professional/treatment/older/ptsd_symptoms_older_adults.asp. Accessed March 4, 2014.
Hyer L, Summers MN, Braswell L, Boyd S (1995) Posttraumatic stress disorder: Silent problem among older combat veterans. Psychotherapy 32: 348�364.
Sleek S (1998) Older vets just now feeling pain of war. APA Monitor 28: 1.
Johnston, D (2000) A series of cases of Dementia presenting with PTSD symptoms in World War II combat veterans. Journal of the American Geriatrics Society 48: 70�72.
Schnurr PP, Spiro A III, Paris AH (2000) Physician-diagnosed medical disorders in relation to PTSD symptoms in older male military Veterans. Health Psychology 19: 91-97.
Krause, N, Shaw BA Cairney J (2004) A descriptive epidemiology of lifetime trauma and the physical health status of older adults. Psychology and Aging 19: 637-648.
Cook JM (2001) Post-traumatic stress disorder in older adults. PTSD Research Quarterly 12: 1-8.
Post-Traumatic Stress Disorder. National Institute of Mental Health
 HYPERLINK "http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-easy-to-read/index.shtml" http://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-easy-to-read/index.shtml. 
Accessed April 3, 2014
Kessler RC, Sonnega A, Bromet EJ, Hughes M, Nelson CB (1995) Post-traumatic stress disorder in the National Comorbidity Survey. Arch Gen Psychiatry 52: 1048-1060.
Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER (1993) Economic burden of depression in. J Clin Psychiatry 54: 405-418.
Franklin CL, Sheeran T,  Zimmerman M (2002)  Screening for Trauma Histories, Posttraumatic Stress Disorder (PTSD), and Subthreshold PTSD in Psychiatric Outpatients. Psychological Assessment 14: 467�471.
Van Zelst WH, De Beurs E, Beekman ATF, Deeg DJH, Van DR (2003) Prevalence and risk factors of posttraumatic stress disorder in older adults. Psychotherapy and Psychosomatics 72: 333-342.
Glaesmer H, Gunzelmann T, Braehler E, Forstmeier S, Maercker A (2010) Traumatic experiences and post-traumatic stress disorder among elderly Germans: Results of a representative population-based survey. International Psychogeriatrics 22: 661-670.
Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL et al (2001) Practice parameter: Early detection of dementia: Mild cognitive impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 56: 1154-1166.
McEwen BS, Sapolsky RM (1995) Stress and cognitive function. Current Opinion in Neurobiology  5: 205-216.
Liberzon I, Taylor SF, Amdur R, Jung TD, Chamberlain K, et al. (1999) Brain Activation in PTSD in Response to Trauma-Related Stimuli. Biol Psychiatry 45: 817�826.

Schuff N, Neylan TC, Lenoci MA, Du AT, Weiss DS, et al (2001).  Decreased hippocampal N-acetylaspartate in the absence of atrophy in posttraumatic stress disorder. Biol Psychiatry 50: 952-959.
Hoge CW, McGurk D, Thomas JL, Cox AL, Engel CC, et al (2008) A mild traumatic brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine 358: 453�463.
Sharpley CF (2009) Neurobiological Pathways Between Chronic Stress and Depression: Dysregulated Adaptive Mechanisms? Clinical Medicine: Psychiatry 2: 33�45.
Lisa MS, Israel L (2010) The Neurocircuitry of Fear, Stress, and Anxiety Disorders. Neuropsychopharmacology Reviews 35: 169�191.
Bremner JD, Innis RB, Ng CK, et al (1997) PET measurement of cerebral metabolic correlates of yohimbine administration in posttraumatic stress disorder. Archives of General Psychiatry 54: 246�256.
Bremner JD, Narayan M, Staib LH, Southwick SM, McGlashan T, et al. (1999a) Neural correlates of memories of childhood sexual abuse in women with and without posttraumatic stress disorder. American Journal of Psychiatry 156: 1787�1795.
Bremner JD, Staib L, Kaloupek D, Southwick SM, Soufer R, et al (1999b) Neural correlates of exposure to traumatic pictures and sound in Vietnam combat veterans with and without posttraumatic stress disorder: a positron emission tomography study. Biological Psychiatry 45: 806�816.
Bremmer JD (2006) Traumatic stress: effects on the brain. Dialogues Clin Neurosci 8: 445�461.
Bremner JD, Vermetten E, Schmahl C, Vaccarino V, Vythilingam M, et al (2005)  Positron emission tomographic imaging of neural correlates of a fear acquisition and extinction paradigm in women with childhood sexual-abuse-related post-traumatic stress disorder. Psychol Med 35: 791�806.
Rauch SL, Whalen PJ, Shin LM, McInerney SC, Macklin ML, et al. (2000) Exaggerated amygdala response to masked facial stimuli in posttraumatic stress disorder: a functional MRI study.  Biol Psychiatry 47: 769-776.
Shin LH, McNally RJ, Kosslyn SM, Thompson WL, Rauch SL, et al. (1999) Regional cerebral blood flow during script-driven imagery in childhood sexual abuse-related PTSD: a PET investigation. Americal Journal of Psychiatry 156: 575�584.
Zlotnick C, Franklin CL, Zimmerman M (2002) Does �Subthreshold� Posttraumatic Stress Disorder Have any Clinical Relevance?  Comprehensive Psychiatry 43: 413-419.
Buffum MD, Wolfe NS (1995) Posttraumatic stress disorder and the World War II veteran. Geriatric Nursing 16: 264�270.
Frueh BC, Grubaugh AL, Yeager DE, Magruder KM (2009) Delayed-onset post-traumatic stress disorder among war veterans in primary care clinics. Br J Psychiatry 194: 515-520.
Andrews B, Brewin CB, Philpott R, Stewart L (2007) Delayed-Onset Posttraumatic Stress Disorder: A Systematic Review of the Evidence.  Am J Psychiatry 164: 1319-1326.
Doege CA, Abeliovich A (2014) Dementia in a Dish. Biol Psychiatry 75: 558-564.
Vida C, Gonzalez EM, Fuente MD (2014) Increase of Oxidation and Inflammation in Nervous and Immune Systems with Aging and Anxiety. Curr Pharm Des. 2014 Jan 30. [Epub ahead of print]
Yehuda R, Golier JA, Tischler L, Harvey PD, Newmark R, et al. (2007) Hippocampal volume in aging combat veterans with and without post-traumatic stress disorder: relation to risk and resilience factors. J Psychiatr Res 41: 435-445.
Chuang YF, Eldreth D, Erickson KI, Varma V, Harris G, et al. (2014) Cardiovascular risks and brain function: a functional magnetic resonance imaging study of executive function in older adults. Neurobiol Aging 35: 1396-1403.
Aribisala BS, Morris Z, Eadie E, Thomas A, Gow A, et al. (2014) Blood Pressure, Internal Carotid Artery Flow Parameters, and Age-Related White Matter Hyperintensities. Hypertension. Jan 27. [Epub ahead of print]
King KS, Peshock RM, Rossetti HC, McColl RW, Ayers CR, et al. (2014) Effect of normal aging versus hypertension, abnormal body mass index, and diabetes mellitus on white matter hyperintensity volume. Stroke 45: 255-257.
Vlisides P, Xie Z (2012) Neurotoxicity of general anesthetics: an update. Curr Pharm Des. 18: 6232-6240.
Perry E (2011) Dreaming and hallucinations - continuity or discontinuity? Perspectives from dementia with Lewy bodies. Conscious Cogn. 20: 1016-1020. 
Singer M, Romero B, Koenig E, F�rstl H, Brunner H (2005) Nightmares in patients with Alzheimer�s disease caused by donepezil. Therapeutic effect depends on the time of intake. Nervenarzt. 76: 1127-1129.
Corbo JM, Brown JN, Moss JM (2013) Galantamine-associated nightmares and anxiety. Consult Pharm. 28: 243-246. 
Mittal D, Torres R, Abashidze A (2001) Worsening of post-traumatic stress disorder symptoms with Cognitive decline. Case series. Journal of Geriatric Psychiatry and Neurology 14: 17�20.
Vasterling JJ, Proctor SP, Amoroso P, Kane R, Heeren T, et al. (2006) Neuropsychological outcomes of army personnel following deployment of the Iraq war. JAMA 296: 519�529.
Veitch DP, Frieda KE, Michael W, Weiner MW (2013) Military Risk Factors for Cognitive Decline, Dementia and Alzheimer�s disease. Current Alzheimer Research 10: 907-930.
Van Achterberg ME, Rohrbaugh RM, Southwick SM (2001) Emergence of PTSD in trauma survivors with dementia. Journal of Clinical Psychiatry 62: 206�207.
Joan MC, Josef IR, Erin C (2003) Possible Association of Posttraumatic Stress Disorder with Cognitive Impairment Among Older Adults. Practical geriatrics. 54: 1223-1225.
Hannah G, Harald E, Annette S, Hannah A, Stephan K, et al (2013) Posttraumatic stress disorder is associated with an enhanced spontaneous production of pro-inflammatory cytokines by peripheral blood mononuclear cells. BMC Psychiatry 13: 40.
Bremner JD, Randall P, Scott TM, Capelli S, Delaney R, et al. (1995) Deficits in short-term memory in adult survivors of childhood abuse. Psychiatry Res 59: 97-107.
Tunajek S. Understanding caregiver stress syndrome. October 2010. 
https://www.aana.com/resources2/health-wellness/Documents/nb_milestone_1010.pdf.     Accessed March 15, 2014
Armon B N Jr. 10 Types of Meds That Can Cause Insomnia. April 8, 2013.
 HYPERLINK "http://www.aarp.org/health/drugs-supplements/info-04-2013/medications-that-can-cause-" http://www.aarp.org/health/drugs-supplements/info-04-2013/medications-that-can-cause-insomnia.html
Accessed March 13, 2014
Ahmed AI, Van Mierlo P, Jansen P (2010) Sleep disorders, nightmares, depression and anxiety in an elderly patient treated with low-dose metoprolol.  Gen Hosp Psychiatry 32: 646.e5-7. 
Kastalli K, A�dli S, Klouz A, Sra�ri S (2003) Nightmares induced by valsartan. Pharmacoepidemiol Drug Saf 12: 236.
Atorvastatin may cause nightmares (2006) BMJ 332: 950.
Reserpine, Hydralazine, and Hydrochlorothiazide (Oral Route).  http://www.mayoclinic.com/health/drug-information/DR600417/DSECTION=side-effects. 
Accessed December 14, 2013
Reserpine, Hydralazine, and Hydrochlorothiazide (Oral Route).  http://www.mayoclinic.com/health/drug-information/DR600417/DSECTION=side-effects
Accessed December 14, 2013










 PAGE   \* MERGEFORMAT 1




 U\^_bcwxy��������%	,	7	8	�	�	�	�	Z
k
)*UVWmn��������������������������������΁�r���h�#�hX�0JCJOJQJ�jh�#�hX�CJUjh�#�hX�Uh~�CJOJQJh�#�h:#�CJOJQJh�#�hX�CJH*OJQJh�#�hX�CJOJQJh�#�hX�h�#�h�"�5�CJOJQJh�#�hX�5�CJOJQJh�#�hd�5�CJOJQJ&xy�7	�	�	G
o����$16�����"����������������������dhgd�Tgd�*bdhgdi gdF!hdhgd\)�dhgd\)�dhgd�+���C
H
;�A���^b����!"*cd���$1��cf������ĵĵĵӦӦĦ��Ħ�Ә�z�m_�_�h�#�h�X�CJH*OJQJh�#�h�X�CJOJQJ!h�#�hX�B*CJOJQJph�h�#�hX�CJOJQJh�#�hX�5�CJOJQJh�#�ht|�CJOJQJaJh�#�h�0�CJOJQJaJh�#�hX�CJOJQJaJh�#�h�_�CJOJQJaJh�#�h;�CJOJQJaJh�#�h�bCJOJQJaJ!lm�������.46��"$%^d����OPW~��)/���������_b�������<�����������������������������������曔������������h�#�hF!h+h�#�hX�5�6�B*CJOJQJaJph�h�#�h�	0CJOJQJh�#�h7g<CJOJQJh�#�h�X�CJOJQJh�#�h�X�CJH*OJQJh�#�hX�CJOJQJh�#�h�3�CJOJQJ:��������� <?��: A C � � � � � � � � � e!i!�!�����˾檣�������wnew�n\n\S\�\h�#�h�g�CJh�#�hN�CJh�#�h{mCJh�#�h�DQCJh�#�h�X�CJh�#�h�X�CJH*h�#�h�)BCJh�#�hX�CJh�#�hX�h�#�h�*b'h�#�hX�5�6�B*CJOJQJph�h�#�h�X�CJOJQJh�#�h�X�CJH*OJQJh�#�h:yCJOJQJh�#�hX�CJOJQJh�#�h7g<CJOJQJ�!�!�!�!"""#"%"+":">"K"Y"["`"z""�"�"�"�"�$%%�%�%T&[&]&k&p&d(n(p(q()(),)�*�*�*�+��������������ɷҷ���������t��t��t��h�#�hZ.jCJOJQJh�#�hZ.jCJH*OJQJh�#�h�X�CJOJQJh�#�h�X�CJH*OJQJh�#�hX�CJOJQJh�#�hX�CJh�#�h�g�CJh�#�h�i�CJh�#�h�X�CJH*h�#�h{mCJh�#�hN�CJh�#�he=aCJh�#�h�C�CJ*�"%--L-l2^:�<9=:=<AaCmCnC�HL�MUO������������������hdh`�hgd����dh`��gd�<���dh`��gd\�dhgd�?Ugd�H%��dh`��gd�Mdhgd�P��`����dh`��gd�/���dh`��gd�T�+�+�+�+�+�,�,----J-L-M-".&.(.;.�.�.�.0#0%0�0�0�0�0q1u1�1�1�1�1�1�1�122c2j2k2�2�2�2�3�3�364�4�4�������˾������˾�˾�˛������˛����˾���ˁ�h�#�h�:CJOJQJh�#�htICJOJQJh�#�h9P*CJOJQJh�#�hX�5�h�#�hX�6�CJOJQJh�#�hW|CJOJQJh�#�hW|CJH*OJQJh�#�h�/�CJOJQJh�#�hX�CJOJQJh�#�hg�CJOJQJ2�4�455,5/5|5�5�5#7&7'7�7�7�7�7�7�7}8~89=9>9W9^9a9�9�9�9�9�9�9�����������ؾ������搃��t�teVh�#�h�W�CJOJQJaJh�#�hi_�CJOJQJaJh�#�h��CJOJQJaJh�#�h9P*CJOJQJh�#�h��CJOJQJh�#�hi_�CJOJQJh�#�h�C�h�#�h�C�CJOJQJh�#�ho�CJOJQJh�#�h�:CJOJQJh�#�hW|CJH*OJQJh�#�hW|CJOJQJh�#�hX�CJOJQJ�9�9*:C:M:P:Z:^:i:w:�:�:�:�:x;�;�;	<?<P<�<�<�<�<�<==������Ŷ������ŋ�|m|mŋ�YE'h�#�h�p�5�6�B*CJOJQJph�'h�#�hX�5�6�B*CJOJQJph�h�#�h_�CJOJQJaJh�#�h�-GCJOJQJaJh�#�hW|CJOJQJh�#�h�v�CJOJQJaJh�#�h)m�CJOJQJaJh�#�hX�CJOJQJaJh�#�hW|CJH*OJQJh�#�h��CJOJQJaJh�#�hi_�CJOJQJaJh�#�hW|CJOJQJaJ=9=:=�=�=�=�=�=2>=>>>H>O>�>�>�>�>�>�>�>�>�>m?r?t?�?�?�?>@E@G@H@����ո������������Ǹ|m�`��Q�ǩmh�#�hW|CJOJQJaJh�#�hW|CJOJQJh�#�h�pCJOJQJaJh�#�hiCJOJQJaJh�#�hE�CJOJQJaJh�#�hS�CJOJQJaJh�#�h�(CJOJQJaJh�#�hIPCJOJQJaJh�#�hW|CJH*OJQJh�#�h�?UCJOJQJaJh�#�h�H%'h�#�hX�5�6�B*CJOJQJph�H@U@b@�@�@�@�@AA9A<AUA\A�A�A�ABB!B[B\B]B^BaCmCnC0I1I�J�JL����������ĵĵӦӵ���Ĉwp�a�R�h�#�hT1'CJOJQJaJh�#�h{s�CJOJQJaJh�#�hX�!h�#�hX�B*CJOJQJph�h�#�hX�CJOJQJaJh�#�h�+rCJOJQJaJh�#�hRDCJOJQJaJh�#�h�?UCJOJQJaJh�#�hOeMCJOJQJaJh�#�hIPCJOJQJaJh�#�h�pCJOJQJaJh�#�hiCJOJQJaJLL�M�M�M�M�M�M\N]NUO(Q6Q�S�ST�T�T�T�T�U�U'V(V
WLWMWNWQW[W\W{W~W�W�W�W�W�W���������ⷪ�����~��~�o��o`�o�o�oh�#�h�NCJOJQJaJh�#�h�~ZCJOJQJaJh�#�h�h�CJOJQJaJh�#�h�{�CJOJQJaJh�#�hW|CJH*OJQJh�#�h�Y`CJOJQJh�#�hX�CJOJQJh�#�h��CJOJQJaJh�#�hD&�CJOJQJaJh�#�hX�CJOJQJaJh�#�h�<�CJOJQJaJ%UOT�V�W�W�W�Y�]�_�_�_�_bb#b�d�dTe������������������h`�h�hdh`�hgd�{�dhgd�{���dh`��gd2k��dh`��gdc'R��dh`��gd�tGdhgd�-�gd�-�dhgd�{�dhgd�(��W�W�W�WXX"X%XWY\Y�YyZ�Z�Z[[1[2[8[<[I[J[Q[W[_[�[�[�[�[.\/\5\8\A\G\c\�\�����ι��ή��������������v���k�k�`�`h�#�hi�CJaJh�#�hvu)CJaJh�#�h"@|CJaJh�#�h~U�CJaJh�#�h>Q[CJaJh�#�h�
CCJaJh�#�h�
CCJH*aJh�#�hc'RCJaJh�#�h�O�CJH*h�#�h�q,CJaJh�#�h�-�CJaJh�#�h�-�!h�#�hX�B*CJOJQJph�h�#�hX�CJOJQJaJ$�\�\�\�\�\u]}]�]�]�]�]�]�]�]�^�^�_�_�_�_�_�_�_q`�`�`�`�`aaa%a(a)a7a;a�a������Խ�Ȳ�����|�s|�|�|�s|sj^�h�#�h==dCJH*aJh�#�h==dCJh�#�h�NCJh�#�h2kCJh�#�hX�CJh�#�hi�CJh�#�h�N6�CJh�#�hX�6�CJh�#�hX�h�#�h�USCJaJh�#�hrCJaJh�#�h�
CCJH*aJh�#�hc'RCJaJh�#�h�l�CJaJh�#�h~U�CJaJh�#�h#CJaJ$�a�a�a�a�abbb#b<b>bDbSbmbybzb}bb�b�b�b�bccScWc�c�c�c d!d"d1d�����ɺ����~�~�~��o�o�c�c�T�T�h�#�h�M�CJOJQJaJh�#�h==dCJH*aJh�#�h:�CJOJQJaJh�#�h�CJOJQJaJh�#�h��CJOJQJaJh�#�hi�CJOJQJaJh�#�h~HCJOJQJaJh�#�hX�CJOJQJaJh�#�hX�6�CJaJh�#�hX�h�#�hX�CJh�#�hi�CJh�#�h�M�CJh�#�h2kCJ 1d>d?dIdYd�d�d�dee>eReTef�f�f�fggg g$g2g3g:gdghglgmgog�gh*h������̾�������}�}p�}��}�}�c�Uc�h�#�h�o�6�CJOJQJh�#�h�o�CJOJQJh�#�hK �CJOJQJh�#�h==dCJH*aJh�#�h==dCJOJQJh�#�h�SRCJOJQJh�#�h�#ECJOJQJh�#�h�#E6�CJOJQJh�#�hX�6�CJOJQJh�#�hX�h�#�hc'RCJOJQJaJh�#�hX�CJOJQJaJh�#�h�M�CJOJQJaJ Temgngog�g�j'm�o,s�wB}C}D}�}�}��������������������������`��gd�|���dh`��gd��gd�|���dh`��gd�}���dh`��gd�
^��dh`��gd�#���dh`��gd�dhgd�o���dh`��gd�n�*h5hJhUhlh�h�h�h�hVi^iwj~j�j�j�jik�k�k�kl0l	mmmm%m&m'mEm\m`mn%n���������ٳ٦������~�q�d~d�W�W�dh�#�h�n�CJOJQJh�#�h==dCJOJQJh�#�h�Q�CJOJQJh�#�h==dCJH*OJQJh�#�h,�CJOJQJh�#�h�#ECJOJQJh�#�hX�CJOJQJh�#�h�hCJOJQJh�#�h�o�CJOJQJh�#�h==dCJH*aJh�#�h�SRCJOJQJh�#�h�6[CJOJQJh�#�h�	DCJOJQJ!%n1n5n�n�nno�o�o�o�o�o�o�o&pdprpsp}p~p�p�p�q�q�q�q�q�q�qDr�r�r�r�rss(s[sbsotvtxt�t�t�tmuquruu�u�u�u�u�u�u�u��������ؾ�˾ؾ��ؾ��ر�ؾؾؾؾؤؖ�ؖ�ؖ�ؖ؉؉��h�#�h�+CJOJQJh�#�h�+CJH*OJQJh�#�h+)qCJOJQJh�#�h==dCJOJQJh�#�h�#�CJOJQJh�#�h�CJOJQJh�#�hX�CJOJQJh�#�h==dCJH*OJQJh�#�h	@CJOJQJ6�umv�v�v�v�v�v�vw�wfyjy{y�y�y�y�y�y�yzz_zgzhz�z�z�zM{N{O{||
||||�|�|�|�|�|�|�|�����������󾱾������������󗊗}p�ph�#�h�\CJOJQJh�#�hH:�CJOJQJh�#�h��CJOJQJh�#�h�u�CJOJQJh�#�h�qCJOJQJh�#�h+)qCJOJQJh�#�h�wBCJOJQJh�#�h�
^CJOJQJh�#�h�+CJH*OJQJh�#�h�+CJOJQJh�#�hX�CJOJQJ)�|�|2}=}?}@}B}J}S}\}]}�}�}�}�}�}�~�~OTWX���������^�b�����佳�����������z���pf�^V�Lh�#�hclmCJH*h�#�h�+^6�h�#�hX�6�h�#�h��5�CJh�#�hX�5�CJh�#�hkECJH*h�#�h��CJh�#�hX�CJh�#�h�|�CJh�#�h�OW6�CJh�#�hX�6�CJh�#�h�|�6�CJh�#�hX�CJOJQJh�#�h��CJOJQJh�#�hH:�CJOJQJh�#�h�u�CJOJQJh�#�hkECJH*OJQJb�c�����܂��#�%�9�=�?�P�T�V�l�����������Ѕх��h�i���������҆؆����	��������������������Ļ�鴣��~o�~�o�~�~��h�#�hGWCJOJQJaJh�#�h�_�CJOJQJaJh�#�hX�CJOJQJaJh�#�hGW!h�#�hX�B*CJOJQJph�h�#�hX�h�#�hEFCJh�#�h�#�CJh�#�hkECJh�#�hkECJH*h�#�h�+^CJh�#�hX�CJh�#�hX�B*CJph�'��Ѕх��e���ӆ�	��������ɏʏ2�������L�����������������������
&Fgd�@�dhgd�@��hdh`�hgd�l�h`�hgdGW��dh`��gd�+^	���4�?�j�~�����؇��"�����#�+�s�|���)�f�v�ˋ̋�.�;�K�w�������Όی���������"�)�*�3�H�T�a�n�u�{�}�����Íč؍���[��������������������طط�㬡��������㬡���¬·�����h�#�h�g�CJaJh�#�h�U8CJaJh�#�h'�CJaJh�#�hEFCJaJh�#�hGWCJaJh�#�h�lCJaJh�#�hX�CJaJh�#�h�lh�#�hX�5�CJ?����������ЎԎՎ֎�&�o�|�������ɏʏ��������X�Y�������H����������������ɻ�������}p}a}�Rh�#�h�MCJOJQJaJh�#�hq{C0JCJOJQJh�#�hq{CCJOJQJ!jh�#�hq{CCJOJQJUh�#�h�@�0JCJOJQJ!jh�#�h�@�CJOJQJUh�#�h�@�CJOJQJh�#�hX�5�CJOJQJh�#�h�@�CJaJh�#�h�g�CJaJh�#�hX�CJaJh�#�h�U8CJaJh�#�hEFCJaJL���~���ڗ��}�6����Y����f�(�ߟ����]��������L�G�e���J�����������������������������
&Fgd�@�J���-�x��ȫl�̬����� ��������$�dzȳ��8�յV������������������������������gd�@�
&Fgd!\��^��gd�@�
&Fgd�@��}���o�Y���q��þ�ȿ����e�A���A��{�5�����!�����a�����������������������������
&Fgdq{C
&Fgd!\���X�!�9���d���-�H����������������������������������������������$a$�h^�hgd�M��`��gd�4�
&Fgd�4���`��gdq{C
&Fgdq{C��^��gdq{C����������������������������� �!��������������������h~�mHnHujh�lUh�lh@\|jh@\|Uh�@�h�MCJaJh�#�h�MCJaJ��� �!������h^�hgd�M6P1�h��/ ��=!��"��#��$��%�������Dp�D���y������K����y������K�Tmailto:mark.detweiler1@va.govyX��;H�,�]ą'c��^���������666666666vvvvvvvvv666666>666666666666666666666666666�6666666666�666666666666hH66666666666666666666666666666666666666666666666666666666666666666�62���� 0@P`p������2(�� 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p������ 0@P`p��8X�V~_HmH	nH	sH	tH	8`�8Normal_HmH	sH	tH	\@\	Heading 1$$d��@&5�B*
CJOJQJtH	u\@\	Heading 2$$d��@&5�B*CJOJQJtH	u\@\	Heading 3$$d��@&5�B*CJOJQJtH	uDA �DDefault Paragraph FontVi�V
0Table Normal :V�4�4�
la�(k �(
0No ListLB@�L	Body Textd�xCJOJQJtH	u0U`�0	Hyperlink>*B*TM@�TBody Text First Indent�h��`�hR/@"RList�h���d��^�h`���CJOJQJtH	u\D@2\
List Continue�hd�x^�hCJOJQJtH	uH@BHHeader

�H�$CJOJQJtH	uH @RHFooter

�H�$CJOJQJtH	u@�@b@�0a List Paragraph
��^��PK!����[Content_Types].xml���N�0E�H���-J��@%�ǎǢ|�ș$�ز�U��L�TB� l,�3��;�r��Ø��J��B+$�G]��7O٭V��<a���(7��I��R�{�pgL�=��r���8�5v&����uQ�뉑8��C����X=��$␴�?6N�JC������F�B.ʹ'�.�+���Y�T���^e5�5�� ��ð�_�g -�;�����Yl�ݎ��|6^�N��`�?���[��PK!�֧�6_rels/.rels���j�0���}Q��%v/��C/�}�(h"���O�
����=������ ����C?�h�v=��Ʌ��%[xp��{۵_�Pѣ<�1�H�0���O�R�Bd���JE�4b$��q_����6L�R�7`������0̞O��,�En7�Li�b��/�S���e��е�����PK!ky���theme/theme/themeManager.xml�M
� @�}�w��7c�(Eb�ˮ��C�AǠҟ����7��՛K
Y,�
�e�.���|,���H�,l����xɴ��I�sQ}#Ր���� ֵ+�!�,�^�$j=�GW��)�E�+&
8���PK!0�C)��theme/theme/theme1.xml�YOo�6��w toc'vu�ر�-M�n�i���P�@�I}��úa��m�a[�إ�4�:lЯ�GR��X^�6؊�>$�������!)O�^�r�C$�y@�����/�yH*��񄴽)�޵��߻��UDb�`}"�qۋ�Jח���X^�)I`n�E���p)���li�V[]�1M<������O�P��6r�=���z�gb�Ig��u��S�eb��O������R�D۫����qu	�g��Z����o~ٺlAp�lx�pT0���+[}`j���zA��V�2�F���i�@�q�v�֬5\|��ʜ̭N��le�X�ds���jcs���7���f����
��W��+�Ն�7����`���g�Ș��J���j|��h(�K��D-����
dX��iJ�؇(��x$(��:��;�˹!�I_�T��S1�����?E��?�����?ZBΪm���U/������?�~����xY���'���y5�g&΋/����ɋ�>���G�M�Ge���D�����3Vq%'#q�����$�8��K�����)f�w9:ĵ��
x}r�x����w���r�:\TZaG�*�y8I�j�bR��c|XŻ�ǿ�I
u3KG�nD1�NIB�s���
��R��u���K>V�.EL+M2�#'�f��i~�V��vl�{u8��z��H�
�*���:�(W�☕
~��J�T�e\O*�tHG��HY��}KN�P�*ݾ˦���TѼ�9/#��A7�qZ��$*c?���qU��n��w�N��%��O��i�4=3��N���)cbJ
u�V�4����(Tn���
7��_?���m-ٛ�{U���B�w�<w���_���$�#��[Ի�8{���(�/�$Ϫ0h݋�F۴��®{L�)#7�i�%�=A�:s�$�),��Qg20pp��f
\}DU4�p
M{��DB��%J������+{�l�C���]��=��5
2F��hsF+��Y��\Ɉ�n�ì��:3���E�[��6�9����`��&45Z!��*��5k8�`Fmw��-��"�d>�z��n���ʜ"Z��x��J�Z��p;�������{/�<�P;��,)''K�Q�k5���q��pN��8�K�Gb�e���
�S��d�̛�\17	�p�a�>��SR!���

3��K4'+�r�zQ
TT��I����Ivt]K�c⫲�K#�v�5+�|��D������~��O@%\w���_�nN[�L��9K���q��g�V�h��n
R!�y+��U�n�;�*&�/H�r��T�	�>��>\
�t��=.Tġ
���S; Z�~�!����P��9gi���C�ڧ!�#	B��,��;�X=ۻ,I�2UW�V�9$l�k���=A��j���;�{�A�P79�|s*Y�����;�̠�[�MC�ۿ�hf��]o��{oY=1k�yV��V���5E8�Vk+֜���\8���0X4D)�!!��?*|f�v�
u���"�x��A�@T_������q��6�4)kڬu�V�7��t�'��%;���i�9s�9�x���,��ڎ-45x�d���8?�ǘ�d�/Y|t��&LIL�J`�& �-G�t�/��PK!
ѐ��'theme/theme/_rels/themeManager.xml.rels��M
�0���wooӺ�&݈Э���5
6?$Q��
�,.�a��i����c2�1h�:�q��m��@RN��;d�`��o7�g�K(M&$R(.1�r'J��ЊT���8��V�"��AȻ�H�u}��|�$�b{��P����8�g/]�QAsم(����#��L�[������PK-!����[Content_Types].xmlPK-!�֧�60_rels/.relsPK-!ky���theme/theme/themeManager.xmlPK-!0�C)���theme/theme/theme1.xmlPK-!
ѐ��'�	theme/theme/_rels/themeManager.xml.relsPK]�
<?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<a:clrMap xmlns:a="http://schemas.openxmlformats.org/drawingml/2006/main" bg1="lt1" tx1="dk1" bg2="lt2" tx2="dk2" accent1="accent1" accent2="accent2" accent3="accent3" accent4="accent4" accent5="accent5" accent6="accent6" hlink="hlink" folHlink="folHlink"/>!�����	,,,/���!�+�4�9=H@L�W�\�a1d*h%n�u�|b�	�����!�hjklmopqrstvwxy{|}~����"UOTe��L�J�����!�inuz������)Vm����X����!�X����X��X��&(/!�����8�@�����������0�(	�
��B
�S����	?�bk���i�iʇ҇W�\�����������������Ê5�9�~���������������������ǐ}�������M�T��������ғړY�`�s�z��������ĕՕݕ��p�x�|�����(�-�1�<�Y�a����ژ���������]�e����"�����&�+�4�8�9�>�_�g�v�|�S�[�j�o�ǞҞ����������U�[������%�ۣ�
����������-�4��������������������Ȩ̨֨ڨ����������ɩŪͪ$�,�;�@�����ȫΫҫثݫ� �/�l�p���������8�@�������V�]������"�2�7�J�S��
����#�5�;��&�c�g�h�p�}���������������������������R�V�����,�4�Y�a����{�������(�.�3�;�öȶͶ׶������������ҷطݷ����������¸r�{�������������P�T�n�u��$�A�I�M�P�������+�/�_�e������/�:�����5�?�c�i������������������a�h���G�M��������������������@�Q�W�Z��������������������"�����
�
#)��13%eSV+.��=@�WZjlg m 	%%F%J%("(A1U1{3�3�5�5o7q7A8D8R�R1T4T�X�X>ZlZYa\ayb~bd,de!evh|h�i�irlul�m�mbrerÉʼn���������6�:���ƞ<�A�6�B�
��ƬǬd�k���M�S����������������������������������"�333333333333333333333333333333333333333333333333333333Zkbzbz�{|������"��y�ܐ�i���������j�)f�����������:
c������������Kw�aZ����������h���^�h`���o(.�
�����^��`����h�H.�
�p�L�^�p`�L��h�H.�
�@���^�@`����h�H.�
����^�`����h�H.�
���L�^��`�L��h�H.�
�����^��`����h�H.�
�����^��`����h�H.�
�P�L�^�P`�L��h�H.�����^��`���o(.�
�����^��`����h�H.�
�p�L�^�p`�L��h�H.�
�@���^�@`����h�H.�
����^�`����h�H.�
���L�^��`�L��h�H.�
�����^��`����h�H.�
�����^��`����h�H.�
�P�L�^�P`�L��h�H.�����^��`���o(.�
�����^��`����h�H.�
�p�L�^�p`�L��h�H.�
�@���^�@`����h�H.�
����^�`����h�H.�
���L�^��`�L��h�H.�
�����^��`����h�H.�
�����^��`����h�H.�
�P�L�^�P`�L��h�H.�����^��`���o()�����^��`���.�p�L�^�p`�L�.�@���^�@`���.����^�`���.���L�^��`�L�.�����^��`���.�����^��`���.�P�L�^�P`�L�.�Kw:
c�y�j�)��������������������																											"�!#�\�Mr�j|�j
A	u
�(V:v57�)�@�MBiIP��:�T�w"kE�&�(2k��Hi �y #.#�H%&�<&T1'vu)9P*�+�q,Z/�	034\5jr58�U8�+97g<WQ>	@�7@|@�)B�wB�
Co#Cq{C�	D� DRD�bD"E�#E�;EEF�oF�-G�tG'~G~H� ItI5K�}K�dMOeM�N�P�DQc'R�SR�	S�USTT�IT�?U}UGW�OW<X�9YT$Z�~Z�6[>Q[!\�\�
^�+^�;`�Y`�0a\<ae=a�*b�?b�c==dhe�ye�g�hF!hZ.jTDj�l{m�=mclm�p�Xp�q+)q�?q�+r�IvVwWwx�~x�y:y�y�z�xz-{\6{"@|@\|Dp|�q|W|�_}-6~[�b�C��/��2��n��~�i_��_��@��|��M�@
�'�;�&����}��@�v��@��#��4�{s��l�4n�t|���:#�Tw��"�V_�'�P�]�B��[�"�n7�cy����I��U�$�X�Ny�C��_�vQ�g��/��v��y�G{�i���1�9%��p���)m�o���\%��3��i���h��S��_��{���e�1;�<E��T��p��p�\)��/��o��5�~U�~��Q��W��Y�,-����-��P�j*��9����o��d��U�f����C�:��[�ic���K ��
�_����O�E��<��@��i��}�S��l�\��u��g��X��
��+��c��m�H:�C�D&�Zs��.�N2��#��&��(��0�G@�,��g�D���d��i�B�N������@�kkkk!��@��Unknown������������G��* ��Times New Roman5��Symbol3.��* ��Arial7���@�Cambria7.���@	�CalibriA���$B�Cambria Math"q���h9l$�l$	�B�ei�B�ei!������20�����K�Q����HP	�	$P����������������������P�2!xx����1MarkJonna G. Detweiler����Oh��+'��0`�������	��
(
4@HPX�1MarkNormalJonna G. Detweiler9Microsoft Office Word@xA�@���ZW�@ԉ�dW��B�����՜.��+,��D��՜.��+,��8�hp��������
���Veteran Affairsie��1Title� 8@_PID_HLINKS�APHVhttp://www.aarp.org/health/drugs-supplements/info-04-2013/medications-that-can-cause-w!dhttp://www.nimh.nih.gov/health/publications/post-traumatic-stress-disorder-easy-to-read/index.shtmlmKmailto:mark.detweiler1@va.gov	

 !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������Root Entry��������	�F�{ǘdW���Data
�������������1Table������6WordDocument����8SummaryInformation(�������������DocumentSummaryInformation8���������CompObj������������r������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������
����	�F Microsoft Word 97-2003 Document
MSWordDocWord.Document.8�9�q

Youez - 2016 - github.com/yon3zu
LinuXploit