PTSD in Combat Veterans With Cognitive Decline
Symptom Reemergence
Both prospective and retrospective studies have shown that PTSD symptoms can evolve, even after a 20-year long symptom-free period, and reemergence of PTSD
symptoms is not uncommon.34,35 A longer delay usually presents with less severe symptoms.36 The unavailability of complete information regarding a patient’s past adjustment to psychological trauma has encouraged some experts to label exacerbation of PTSD symptoms precipitated by cognitive disorder as delayed onset PTSD. In most cases, it seems that this is more accurately described as a recrudescence of symptoms that were better managed previously. The picture is clouded by the often bizarre and extreme manifestation of PTSD symptoms in patients with memory disorders. The course of PTSD often does involve a delay between the time of exposure to trauma and symptom manifestation. In addition, symptom intensity can fluctuate significantly over the course of this often chronic illness.
The suffering associated with PTSD is often personal and concealed. Family and other collateral sources may be able to report only on social and occupational functioning. The authors recommend increased attention to proper assessment of (1) remote trauma history in patients being evaluated for memory disorders; and (2) cognitive decline in patients with history of PTSD. The problem of underreported cognitive decline is well known, although its extent is not. Early detection may help to mitigate the combined effects of these conditions. Aggressive early treatment of symptoms during the onset of cognitive dysfunction may prolong patients’ ability to remain at home.
Patient Care
Mr. B’s case was marked by significant tension in the home. Education and support of caregivers is essential to maintaining care in the least restrictive setting, such as the patient’s home. Families might be utterly bewildered by a patient’s apparently sudden preoccupation with traumatic memories. For many, this might be the first time they have ever heard the patient speak at length about the traumatic events. Simple strategies to limit exposure to distressing stimuli, improve grounding, and understand the effects of trauma can be taught. Psychopharmacologic intervention to improve sleep, slow cognitive decline, and decrease behavioral disturbances may be indicated.
Behavioral disturbance is frequently encountered when treating patients with cognitive impairment. In the limited literature on the subject, patients with both PTSD and cognitive impairment do not seem to be more prone to behavioral disturbance than patients with cognitive impairment alone.9 However, the case reports cited here demonstrate a high incidence of violence or potential violence in these comorbid patients. Routine assessment of potential harm from firearms or other weapons should be conducted assiduously.
It is possible that Vietnam War veterans may be more likely than previous veterans to exhibit behavioral disturbances in the context of cognitive decline and PTSD. A higher incidence of aggression, violence, and resistance to authority has been documented in this group.37 Substance abuse and dependence also occurs with higher frequency in this cohort and may complicate treatment of cognitive impairment and PTSD.38,39 A large number of these veterans may initially present to non-VA health care providers and these clinicians may be unaware of a patient’s prior combat exposure and thus fail to accurately assess PTSD.
Although the relation of PTSD and vulnerability to dementia has been well established, it is unknown how the presence of PTSD symptomatology impacts dementia symptoms or how the presence of dementia impacts PTSD symptoms. Posttraumatic stress disorder and dementia share similar risks like traumatic brain injury, low IQ, poor education, substance abuse, precipitated by stressful life events and impairment of coping, physical health and related risk factors. Unmasking PTSD symptoms resulting from dementia is a well-known phenomenon described in recent studies on late-onset stress symptomatology (LOSS).5,10,40
Since PTSD is a major risk factor that doubles the chance of developing dementia, mandatory screening for dementia in older patients along with assessment of other risk factors as a standard of care may help physicians in the early detection and initiation of care. Recognition of LOSS may be an important milestone in the treatment of delayed onset PTSD, which is considered a normal aging process and a premorbid stage of PTSD.10,40
Although there is no established treatment, early psychotherapeutic approaches like reminiscent therapy along with psychoeducation may be beneficial in patients with LOSS.40-42 Effective treatments for PTSD with patients with dementia may be challenging, though dementia was not found to be a barrier to implement prolonged exposure therapy in patients with mild cognitive impairment.43 Patient aligned care teams can be an ideal approach for the care of these veterans.
Conclusion
Posttraumatic stress disorder and dementia are well studied and documented disorders, although PTSD has been studied far more extensively in younger populations. Accounts of comorbidity of the 2 disorders are limited in the literature. Individuals may exhibit PTSD symptoms prior to the onset of dementia. They also may develop or uncover long quiescent symptoms of the disease. The populations of patients with PTSD and dementia are recognized, but their characteristics are largely unstudied and thus unknown.
Although the authors believe this to be a phenomenon of unrecognized coexistence of the 2 disorders, a disproportionate number of patients may be found in certain populations, especially among veterans. There is good evidence to expect increased numbers of these patients in the VA system, especially given the relative frequency of PTSD symptoms in aging cohorts of VA patients.
