Dr. Regina Koepp: according to the National Center for PTSD, up to 90% of older adults have experienced a traumatic event. In fact, PTSD symptoms or post-traumatic stress disorder symptoms can emerge with age, meaning that even a traumatic event experienced decades ago, the symptoms related to that event can emerge with age. Here are some reasons why.

For more than a decade, I worked with older veterans at the Atlanta VA healthcare system and often people would come to my office for an intake after retirement, and what they would share with me is that once they retired, they started to experience more symptoms of earlier trauma from combat or trauma from childhood maltreatment. And what they described was that having structure with work. Prior to retirement, having a nine to five and working in collaboration with others, built in natural scaffolding and systems of support that helped them cope with earlier traumatic memories. And now with retirement, they didn't have those same systems of support or coping.

And so now were experiencing an emergence of trauma symptoms. Other adults would share with me that they recently received a new chronic health or life altering medical diagnosis, and this vulnerability that can come with physical health condition called into the room, other reminders or vulnerabilities from previous or historical traumatic events.

Sometimes I say that. New trauma reminds us of old trauma and it calls all the old trauma into the room. And so this can also contribute to a reemergence of PTSD symptoms later in life when a person has a new diagnosis of a medical condition.

And this is particularly relevant during older adulthood because among people 65 and older, more than 80% of them have a chronic health condition. And if people are feeling that their life is in jeopardy due to a chronic health condition or a life altering health condition, then this can call up old traumatic memories as well.

An increase in stressors or loss can also increase or reemerge PTSD symptoms. And so in older adulthood there are a lot of transitions and experiences of loss from moving to retirement to loss of a loved one . i've worked with many older adults who have adult children who die unexpectedly or expectedly, but tragically nonetheless, because it's out of what we expect in terms of the sequence of time and the sequence of loss that as parents we're supposed to die before our children. Traumatic losses also increase the reemergence of old traumatic memories. Or anything from a traumatic loss, like the deaths of an adult child or a grandchild to expected losses like retirement or death of a friend after a long illness, can also call into the room old traumatic memories. Further, because cognitive disorders are more common among older adults than other age groups, when our brain is vulnerable related because of, a cognitive disorder, like a dementia disorder, that can also make us more vulnerable to mental health conditions like depression, anxiety, and trauma history, and PTSD symptoms. Finally, something that we don't talk enough about, but I think is incredibly important is this idea that part of the healing process that happens as we age is that we bring together the strands of our life into a tapestry with the dark elements and the light elements, weaving them together, and there is a natural phenomena that happens that when we have unresolved traumatic memories, or even if they had been resolved earlier points in life because of the dynamics that I mentioned earlier, there can be a reemergence of trauma symptoms in an effort to understand and bring together the strands of our life and a sort of life review process, and as part of a healing process to build meaning and find coherence and integration in our life. It may be painful, but it may not be pathological. Still grist for the mill in therapy and important in healing and therapeutic work.

So trauma leaves a long-term imprint. It isn't only psychological, it's physiological as well. We know that when people have exposure to trauma and unresolved post-traumatic stress disorder. That there's an increased risk for heart disease. And we also know that what's good for the heart is good for the brain, and what's bad for the heart is bad for the brain.

Heightened levels of cortisol, increase inflammation and inflammation, increases the risk for brain health conditions as well, like dementia disorders. But it's not just this physiology that we need to keep in mind. It's also research that is pointing to this as well.​

Let's talk about the correlation between post-Traumatic Stress Disorder and dementia.

There was a landmark study that was published in 2010 that found that veterans with combat trauma had a twofold increase of developing any type of dementia, compared to those without PTSD. Even after adjusting for other risk factors.

And of course when a person experiences trauma, they aren't only at risk for developing post-traumatic stress disorder, they're also at risk for developing other mental health conditions like anxiety, depression, substance use disorders, and insomnia, panic attacks and or panic disorder, and so on.

And so the hunt study in 2024

also showed that symptoms of depression and anxiety linked to unprocessed trauma, increased the risk for dementia as well even more than 30 years later.

There is also evidence that people experiencing racism based trauma like black Americans in the United States. Also have higher rates of dementia, and some of this is attributed to racism related stress and weathering as a result of racism related stress, meaning accelerated aging of organs that increase risk and vulnerability for dementia disorders.

And so it's critical that we're thinking complexly and holistically at how trauma influences our lifespan and our brain health across the lifespan.

And so what does this mean? First trauma. Is identified as a risk factor for dementia. At this time, it's correlational. It is not causal. We still need more and more research to better understand this, but we also know that if we treat trauma and we help people to regulate their nervous system and have a full, long, high quality of life, that this can be a protective factor for the brain.

Yet, here's the challenge is that trauma and PTSD symptoms or anxiety and depression or panic disorder related to trauma history often goes undetected and untreated among older adults. And so I wanna talk about why. The first is underreporting. There's often stigma, of course, associated with sharing about trauma experiences.

One of the symptoms of post-traumatic stress disorder is avoidance, and so the person might avoid reporting as a symptom of PTSD itself, and so it becomes this really complex.

There's often under-reporting due to shame, stigma, and generational silence around, I don't wanna share my emotional baggage. Often when it comes to older adults and trauma, a family member is concerned about the older person's current mental health experience, and so they may be encouraging the older person or your older client to go to mental health treatment.

And if they're in the room with your older client, your older client may be reluctant to share for want to protect the relationship with the person and also for want to protect themselves and the vulnerability that often arises in doing trauma work. And so when I'm working with family members, I often will say, we'll meet together, then I'll meet with the identified client, alone. With the caregiver if appropriate, alone, and then all back together. And so in doing this work, you need to be very flexible in your approach, but also have enough clinical authority so that you're guiding the approach. Because sometimes very distressed family members will want to guide the approach and you with your clinical authority and knowledge and wisdom in providing care will need to be a clear manager of how the sessions go.

I've worked with many World War ii, Korean War and Vietnam War veterans

where it is not appropriate to talk about their combat experience with their family members. Maybe their family members don't know how to respond. Their family members aren't trained mental health providers, even if they are, they're not that person's mental health provider. And so it takes a lot of sophistication in navigating trauma assessment with older adults, especially when a caregiver is involved and needing to be involved.

You don't wanna alienate the caregiver, but finding a way to protect the therapeutic relationship and the trauma work without alienating the caregiver takes finesse and grace.

And so I talk more about how to do caregiver family therapy in my large certificate program, which is an 18 hour continuing education course on meeting the mental health needs of older adults.

So I hope you check that out when enrollment opens.

Okay, let's get back to what keeps older adults from what keeps trauma from being identified among older adults?

Another is avoidance and with post-traumatic stress disorder avoidance is one of the hallmarks symptoms of post-traumatic stress disorder. And so avoid anything that will remind you of the traumatic event. So if a clinician's gonna be asking, tell me about traumatic events in your life. It's gonna be hard for the person who's experiencing PTSD to provide that information because one of the symptoms in and of itself is avoidance.

And so they may not wanna talk about it. They may avoid coming to appointments and so on. And so that's another reason why trauma goes undetected and untreated. And then that's avoidance from the client side. But then there's also avoidance from the clinician side, especially when working with older adults.

Back to this idea of ageism, that the older person can't handle this difficult conversation when in fact, as we age, we develop more and more resilience and better problem solving and better emotion regulation. And this isn't like older adults have it and you don't. This is you and I, and each of us as we age, we cultivate this and all of us to different degrees, of course, because where we start out is very different. But this happens throughout our maturity process as humans. And so what happens though is we have this false belief that older adults may not be able to handle this conversation and so we fragilize them or will it matter now if we do trauma work And so we dismiss their opportunity to heal and grow and transform from these experiences.

And that is ageism in action. And so as professionals, we need to counter that. We need to invite the older person into a conversation and change the narrative that we have been fed by society about older adults in their vulnerability as we age, we have more physical vulnerability, but greater psychological strength.

And so use the psychological strength in these conversations. And so when you find yourself being reluctant or uncomfortable asking for fear, that it will tip the older person over the edge or or the older person may be too fragile to handle it. Think again. And of course we need to be thoughtful and cautious and clinically sound in doing this work, not forceful. But when the ageism creeps up, challenge it and go in the other direction.

And because the truth is. Older adults are capable of change. There is no expiration date on healing, transformation, and growth, and are as deserving as mental health care as anybody else. And trauma treatment does work for older adults too.

The other important reminder is that treating trauma now at any age is not only alleviating suffering now and helping the person to restore full quality of life and engagement with life. It's also protecting the brain down the road and dignity and autonomy, and especially for people who have history of trauma autonomy is key. In wellness and health, and so doing trauma work today can help to improve brain health and mental health down the road.

I've put together a trauma-informed care guide for professionals when working with older adults. And so you can download that at mentalhealthandaging.com/tic for Trauma-informed care. And I'll also have a link for it below in the show notes.

So as a professional, here are five things that you can do to provide a trauma-informed care approach to prevent dementia. The first is to screen for trauma. There are various screening tools for primary care and mental health care. The important thing is that you understand the clinical utility of this.

If you're working in primary care and you're screening and you're screening for trauma, but you have no resources to send that person or referral options for that person, it may not be the best. And you can't do anything clinically with the information you get, but you may be opening Pandora's box.

Think about that, right? You wanna be prepared if the person says yes to have age appropriate and culturally appropriate resources for the person when you're screening for trauma, for where you will refer them. We have a national provider directory of licensed mental health providers who work with older adults.

You can send them to that directory at mental health and aging.com. They're all independently licensed providers who are specialized to work with older adults, but there are other resources in your community as well. So before you screen, be clear about where you will send people, especially if you're in primary care.

If you're in primary care, I'll put a link to a brief trauma screening tool that you can use that's used widely in primary care for mental health providers. Screening needs to have a clinical utility to it. And then you need to clearly understand what treatment options you have and if you have the training that you need to offer that trauma treatment. And if you don't, then you also need to know where to refer that person.

When screening, don't ask for graphic details. And sometimes with screening for trauma, the person can get very flooded and start to give details. And I would say in a first interview, or even early in your relationship when you're not yet doing deep trauma work, to be careful with that and to try to help the person contain that.

Because you don't want the person to become flooded without the skills to manage that flooding. And so

and so you might say something like, when you're screening, "many people your age have lived through very complex and painful life experiences. Have you noticed any painful experiences from your life reemerging for you or coming up for you today and getting in your way of living the life that you want."

Or "sometimes what we've experienced earlier in life can rear its head at this stage in our life and come up as anxiety or depression or sleep problems. Have you noticed any of that? Do you have any concerns about that?" And so just. Just getting the conversation going. Even if the person says no today, like for years and years I worked with as I mentioned with veterans, but also in other trauma clinics at Grady Hospital and and elsewhere.

And even if the person is not ready today, just that little offering, just opening the door may help them to bring to circle back to that conversation in a follow-up meeting. After trust has been developed, I have worked with many older adults who a couple of months into our work we'll begin to discuss their trauma history and it is a very deep and meaningful, profound and beautiful work to work with older adults recovering from trauma.

And if a person is sharing their traumatic experience with you, it's really important to normalize and validate. " Thank you so much for sharing your experience with me. I want you to know that you're not alone with this" and " thank you for sharing this experience with me. It makes sense that these earlier life experiences would be coming up for you now, because sometimes new vulnerability or new trauma calls into the room old vulnerability and old trauma. And so it makes sense it's coming up for you now.

You're not alone with this and we can help." And if you can provide that trauma treatment, fabulous. And if you don't, be sure to refer them to somebody who can help them. Number three is to treat the symptoms even if trauma is not disclosed, sometimes it would take months for a person to warm up to trusting me and to understanding how the psychotherapeutic process works to trusting themself in this process, to understanding how to regulate emotions even when deep emotional content is being explored. So in that process when you have either a knowledge of trauma history, or a sense that something may be brewing underneath, focus on the presenting symptoms that the person is willing to talk about now, if it's sleep or depression or relationship concerns, that not dismissing the other symptoms that you have a hunch or are stemming from this deeper rooted trauma.

It's okay to treat the symptoms. And as you're doing that, you're building your relationship with the client. You're building their sense of mastery over the therapeutic process. They're building understanding of your clinical relationship to hold the more painful content underneath when they're ready.

And so this initial work is really important for doing the deeper level work that hopefully will come with trust, focus on alleviating some of the symptoms from sleep and anxiety and depression and relationship distress, even if you have a hunch that there's trauma underneath it.

Number four is to use trauma-informed and trauma-focused techniques. So one is pacing to follow your client's lead. I would say there's a caveat to this with flooding, and so sometimes if you move from the client talking about their traumatic event, and this is early in the treatment course and you're.

You're not at a place where the details are helpful if the person is flooded, to be sure that you're using other trauma techniques like grounding to help them get back into their center, into their sense of groundedness. And so pacing. Let the client lead with what they're ready for, but then also teaching and using other techniques like grounding if they're getting flooded and are not ready for that level of work.

Also to be sure that your therapeutic relationship can hold the deeper intensity work or the higher intensity work, and that you can provide a therapeutic container for the work for the patient and the patient trusts that container and you trust that container as well. I think that's critically important also to trust the person's ability to emotion regulate before doing that deeper level work is really important as well.

And then also of course, providing psychoeducation, helping the client to understand how trauma can impact their physiology and their brain health. And especially with older adults, this can help with motivation for doing this work. Sometimes older adults will say that I've worked with will say.

I've come this far. Do I really wanna open that up now? And really, of course, it's their choice. They get to decide. But sometimes what will help them to make that decision is just to know what does treatment look like with you? How will this help their their mental and physical and brain health down the road, and that might be information that they could really use to make this decision for themself that with treatment and with better emotion regulation and symptom management, perhaps we could turn the volume down on the intensity that they're experience with experiencing with the traumatic memories.

And number five is to build connection and integration of their life experience.

This might include meaning making, legacy building, and life review. In addition to some of the trauma work.

Reconnecting with culture or spirituality and family, maybe repairing ruptured relationships that came out of the symptomology related to trauma long, lifelong trauma, or decades of trauma or un unprocessed trauma. And so what I think is also really valuable in this fifth. Tip is this notion that of the notion of post-traumatic growth for older adults.

So while 90% of older people have experienced a traumatic event, about 50% of them, about half of them go on to experience also post-traumatic growth. And one of the elements of post-traumatic growth. Connection and community. And so there's a saying that healing happens in community. And when it comes to post-traumatic growth, that is true. Being with other people who have shared in a similar traumatic event can be incredibly healing. And when I worked with veterans, I had a later life depression and anxiety group, but it also included PTSD naturally by nature of who I was serving.

I led for seven years, a late life men's group at the va. The composition of the group was about seven black men who had experienced significant trauma in their lives. And this group, when I tell you, they met every two weeks, same time, rain or shine, they always showed up for each other. This was one of the most profound and healing experiences, I think, for them and for me.

It was so beautiful to be a part of their. Community, their bonding, their healing process, their experiences of being black men and veterans. It was the most profound experience I have had in my career and I. We met until some of the group members began to die and they would visit each other in the hospital.

This was before telehealth. We even would FaceTime with somebody on hospice home-based hospice to participate in the group. So we had a sense of community in the last stages of his life, and there is something that happens in community, in building these bonds and having a shared purpose toward healing and growth.

This was all for men over 75. It was powerful. And so I would invite you as clinicians to think of ways. Could you offer a group, and maybe you don't do it for seven years, but could you offer even a time limited group for. People living with a certain mental health condition or striving toward a certain healing process, it can be incredibly moving and profound and provide a sense of community and support, and I believe post-traumatic growth.

I'm also gonna do another video to talk about, i'm also gonna do another video to talk about modifying the environment. When a person living with dementia has a history of post-traumatic stress disorder.

This can get very complicated in families and also in long-term care, memory care communities who don't have the training and resources to understand how to respond to somebody who's triggered when living with dementia. And so I'll do another video on that as well. But download that trauma informed care guide.

It's at mentalhealthandaging.com/tic for Trauma informed care, and I'll put a link to it in the show notes below, along with lots of other resources as well. And a link to the show notes where you can find the research studies that I mentioned before and some other resources.

Here's the bottom line. Trauma symptoms can reemerge with age. When people have trauma, they can develop PTSD, but other mental health conditions like depression, anxiety, insomnia, panic disorder, and so on, and these conditions increase the risk for dementia as well.

Here is the good news. We have treatment available for each of these mental health conditions, and they are equally effective for older adults. And so there is a lot that you can do to meet the mental health needs of older adults and bolster brain health down the road as well as dignity and autonomy because there is no expiration date on healing, transformation and growth.

You have a really important role in helping to meet the mental health needs of older adults, so thank you for being here and doing your part.

If you like this episode, will you like and subscribe and share it, because it really does help other people to find this important information and this information is missing as it relates to mental health and aging.

And so that is why I built the Center for Mental Health and Aging. I am Dr. Regina Koepp. I'm a board certified clinical psychologist and Geropsychologist, and I founded the Center for Mental Health and Aging to make sure that you have all the tools you need as professionals to meet the mental health needs of older adults.

I'll see you next time. Bye for now.