Case Report, J Trauma Stress Disor Treat Vol: 7 Issue: 2
An Atypical Presentation of Trauma-related Disorder in Geriatric Patients
Ayotomide Oyelakin*, Alexander Maksymenko, Oluwole Jegede, Tolulope Olupona, Wil Germain, Kang Yu and Ayodeji Jolayemi
Department of Psychiatry, Interfaith Medical Center, New York, USA
*Corresponding Author : Ayotomide Oyelakin
Department of Psychiatry, Interfaith Medical Center, Brooklyn, New York, USA
Tel: (718) 613 4334
Received: April 13, 2018 Accepted: April 26, 2018 Published: May 02, 2018
Citation: Oyelakin A, Maksymenko A, Jegede O, Olupona T, Germain W, et al. (2018) An Atypical Presentation of Trauma-related Disorder in Geriatric Patients. J Trauma Stress Disor Treat 7:1. doi: 10.4172/2324-8947.1000185
Patients older than 65 years who have experienced trauma in earlier years tend to present differently compared to the younger age group. This atypical or complicated presentation is sometimes masked by the presence of comorbid diagnoses, role changes and functional loss such as cognitive impairment. This is a case report of a 75-year-old female with a history of multiple traumatic events that presented with disorganized behavior and appeared internally preoccupied. On further evaluation, her symptomatology was found to be tied to re-experiencing memories of the traumatic events. In elderly patients like our patient, the clinical presentation may not meet the full DSM-5 criteria for Trauma and Stress-related
Disorders; however, remembering or reliving the trauma could cause considerable distress and present as some other psychiatric illness. This makes it imperative that a thorough evaluation and exploration of the past psychiatric history of patients with the history of trauma be done for a definitive diagnosis, and effective management.
Keywords: Trauma; Elderly patients; Re-experiencing memories; PTSD, PTSD; PCL-S
The experience of trauma and stressful life events in early life predisposes to the development of various mental health conditions, including Post Traumatic Stress Disorder (PTSD) . Lifetime prevalence of PTSD is 6.1-9.2% in the general adult population in The United States and Canada with one-year prevalence rates of 3.5-4.7% [2,3]. Patients 65 years and above who have experienced trauma in earlier years tend to present differently compared to the younger age group . Age of onset of trauma related disorder in the older adults tend to be later and the course chronic . As the elderly population is expected to exceed 70.3 million by 2030, the need for in-depth understanding of the sometimes different presentation in the clinical assessment and management of Trauma and Stress related Disorders in that population is crucial . Trauma in the elderly is often complex and complicated by the presence of comorbid psychiatric diagnoses which often mask the clinical presentation . Role changes, functional losses including physical and cognitive impairments and decreased availability of avoidance based coping strategies could also make coping with memories of trauma in earlier life more difficult for aging patients, and impact the way they present to the clinician .
We present the case of a 75-year-old African American female with past psychiatric history of Schizoaffective disorder who was brought in by emergency personnel activated by her daughter on account of disorganized behavior. At presentation, the patient was disheveled, uncooperative, appeared internally preoccupied, and did not appear to be adequately processing information. On re-evaluation when the patient had symptomatically improved, she revealed a history of multiple trauma including rape 54 years ago, gunshot injury 12 years ago and traumatic loss of a grandchild due to a stray bullet 10 years ago. Most significant, she reported flashbacks of the incident of rape 54 years ago which triggered her presenting symptoms. Further evaluation revealed that her presenting symptoms and deterioration in her mental state was tied to the loss of her grandchild and rape heightened by the perceived sighting of the man she thought raped her. Her symptomatology was tied to her re-experiencing memories and preoccupation with the man who raped her. The patient reported the man had a particular smell, which she was unable to describe, which had triggered her symptoms. Patient was Hypervigilance and had a strong avoidance of emotions and suppression of feelings preferring not to discuss her re-experiencing memories. The patient scored 20 on the Post-traumatic Stress Disorder Checklist (PTSD PCL-S), 20 on the Mini-Mental State Exam (MMSE) and 16 on the Montreal Cognitive Assessment (MOCA). Her deficits on the MOCA were in the visuospatial/executive, object naming, language, abstraction and delayed recall domains. On the PTSD PCL-S checklist, the patient scored high with avoidance of thinking, talking or having feelings related to the trauma. Urine toxicology was negative for illicit substance. Complete blood count, complete metabolic panel, thyroid function tests were within normal limits. A computed tomography (CT) scanning of the head did not reveal any significant finding. During the course of admission, the patient was initially placed on Haldol 4 mg daily per oral which was discontinued when she was diagnosed with Trauma related Disorder. She was commenced on Sertraline 25 mg daily per oral with good response and resolution of presenting symptoms. At discharge, patient was no longer preoccupied, had no intrusive thoughts, and had improved reality testing. She was engaged in her care and had positive interactions with others.
There is limited literature on the presentation of trauma in the elderly who have had traumatic experiences at an earlier age . Most studies on PTSD in the elderly are done on war veterans or Holocaust survivors due to belief that PTSD symptoms are more prevalent in younger age groups . It is of note that in elderly patients like our patient, the clinical presentation may not meet the full DSM-5 criteria for PTSD; however, remembering or reliving the trauma could cause considerable distress and present as some other psychiatric illness such as major depression, and severe anxiety . Individuals with a sexual abuse history are at higher risk of developing PTSD . Symptoms of past trauma in this group of patients may be delayed and may show an atypical picture leading to a challenge in diagnosing as patients often present with symptoms suggestive of other psychiatric illness . This patient had a strong avoidance of emotions and numbing which impacted her psychopathologic diagnosis. Also, in this patient, the presence of mild neurocognitive impairment as evidenced by her MMSE and MOCA score impacted the clinical presentation and diagnosis. This brings to play the importance of a history and evaluation in ruling out other psychiatric diagnoses from Trauma Related Disorders in elderly patients. A thorough evaluation and exploration of the past psychiatric history are imperative for a definitive diagnosis, and effective management .
- Mayo D, Corey S, Kelly LH, Youngquist AL, Stuart BK, et al. (2017) The Role of Trauma and Stressful Life Events among Individuals at Clinical High Risk for Psychosis. Front Psychiatry 8: 55.
- Sareen J, Murray BS, Richard H (2018) Posttraumatic stress disorder in adults: Epidemiology, pathophysiology, clinical manifestations, course, assessment, and diagnosis. UpToDate Topic 500 Version 28.0.
- Goldstein RB, Smith SM, Chou SP, Saha TD, Jung J, et al. (2016) The epidemiology of DSM-5 posttraumatic stress disorder in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions-III. Soc Psychiatry Psychiatr Epidemiol 51: 1137-1148.
- Kaiser AP, Schuster Wachen J, Potter C, Moye J, Davison E, et al. (2017) Posttraumatic Stress Symptoms among Older Adults: A Review. Stress, Health, and Aging Research Program (SHARP).
- Pietrzak RH, 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. Am J Geriatr Psychiatry 20: 380-390.
- Ladson D, Bienenfeld D (2007) Delayed Reaction to Trauma in an Aging Woman. Psychiatry (Edgmont) 4: 46-50.
- Bottche M, Kuwert P, Knaevelsrud C (2012) Posttraumatic Stress Disorder in Older Adults: An Overview of Characteristics and Treatment Approaches. Int J Geriatric Psychiatry 27: 230-239.
- Sutker PB, Allain AN, Winstead DK (1993) Psychopathology and Psychiatric Diagnoses of World War II Pacific Theater Prisoner of War Survivors and Combat Veterans. Am J Psychiatry 150: 240-245.