Special Issues in Geriatric Patients

Steven Tam, MD

Advances in ACEs research have shown relationships between childhood adversity and poor mental health, physical health, and social outcomes later in life. More studies are needed to understand the mechanisms of these relationships and to aid in the development of treatment strategies for these conditions. With advances in life expectancy, the older adult population represents one of the fastest-growing age groups in the United States and providers will need to understand the impact of ACEs in order provide the best geriatric care.1  Faced with issues such as fragility from medical conditions, decreased physical and cognitive reserves as well as certain geriatric syndromes such as dementia, an older adult may find more difficulties contending with the mental and emotional health problems along with poor social outcomes that may have resulted from ACEs developed earlier in adulthood.

Understanding the history and natural course of earlier life adversities along with their sequelae and how this affects treatments is important to providing proper care to the geriatric patient.  For example, a psychologist providing counseling and cognitive behavioral therapy for depression in an older adult may find it useful to know that an individual had a traumatic or abusive childhood experience. This is especially true if treatment of the depression has been refractory to standard treatment modalities.

Successfully managing ACEs-related issues requires providers to consider the perspective of the individual and how these experiences may influence an individual's ability to manage the situations that arise in the elder years. Early adverse child experiences have been linked to some maladaptive behaviors later in life, including alcohol and drug abuse2 and a higher risk for attempted suicide.3 With some of the social and life-changing events faced by our older adults, such as the loss of social support networks and increasing fragility of health as well as a medical condition such as dementia, lacking the proper adaptive skills will impair one’s ability to face these events.

The role ACEs may play in the development of certain issues for the geriatric population should also be considered in the context of violence and abuse across the lifespan.  One example is the risk for elder abuse.  Elder abuse refers to an act by a caregiver or other causing harm or threatening harm to the health or welfare of the older adult.4 Exposure to child abuse/maltreatment is a risk factor for the development of abusive parenting and domestic violence later on, which in turn become a risk factor for elder abuse later in life. Understanding such relationships and potential psychopathology may be a crucial step to preventing elder abuse.

Another example is the role childhood stressors may play in the development of a geriatric syndrome such as dementia.  Studies have pointed to an association between psychological stress in adulthood and the development of dementia, possibly through activation of the hypothalamic pituitary adrenal axis and increasing levels of glucocorticoid hormones.5 One study looking at war veterans suggested a greater prevalence and incidence of dementia in older veterans with PTSD.6,7 With ACEs linked to depression, PTSD, and other psychological problems, one possibility is that the stressors predisposing to dementia may start very early on.  As future research investigates the prevention of dementia, attention has been focused on examining the cognitive health of the adult population.  Perhaps we should begin assessing cognitive functioning earlier including the cognitive health of adolescents as well as adults.

As research moves forward examining the impact of ACEs on adulthood, little is known regarding the effect on the older adult. Further investigation is needed to (a) examine the role and effects ACEs have on mental health and other illnesses adults contend with and (b) how childhood stressors contribute to specific geriatric events and syndromes.

References

1. United States Census Bureau. 2010 Census Shows 65 and Older Population Growing Faster Than Total U.S. Population.

2. U.S. Department of Health and Human Services Administration for Community Living. What is Elder Abuse?

3. Douglas KR, Chan G, Gelernter J, et al.  Adverse childhood events as risk factors for substance dependence: partial mediation by mood and anxiety disorders.  Addict Behav. 2010; 35(1): 7-13.

4. Brodsky BS, Stanley B.  Adverse childhood experiences and suicidal behavior.  Psychiatr Clin North Am.  2008; 31(2):223-35.

5. Charles E, Bouby-Serieys V, Thomas P, Clément JP..  Links between life events, traumatism and dementia; an open study including 565 patients with dementia.  Encephale. 2006; 32(5 Pt 1): 746-52.

6. Yaffe K, Vittinghoff E, Lindquist K, Barnes D, et al.  PTSD and risk of dementia among US veterans.  Arch Gen Psych 2010; 67: 608-613.

7. Qureshi SU, Kimbrell T, Pyne JM, Magruder KM, et al. Greater prevalence and incidence of dementia in older veterans with PTSD.  J Am Geriatr Soc 2010; 58: 1627-1633

© 2015 by Academy on Violence and Abuse