According to the Department of Veterans’ Affairs (DVA), there are currently more than 80,000 veterans over the age of 60.
Through medical advances, these veterans are enjoying increasing longevity. The unique nature of military service means many veterans have complex mental health issues, and with ageing these can provide particular challenges in diagnosis and treatment for primary care physicians.
Late life is a time of change, necessitating a holistic biopsychosocial approach to mental health.
Biological changes include typical ageing, plus the onset of many diseases (hypertension, cardiac and cerebrovascular disease, osteoarthritis, and cancers) with their associated disability and treatment. Psychologically, existential questions arise such as, “Have I lead a meaningful life” and “What legacy will I leave”. Socially, individuals have to cope with retirement, illness and death of friends and partners, and increased reliance on others.
Most mental health problems are chronic, and don’t ‘just go away’. Vulnerable individuals frequently experience an exacerbation in response to these changes.
Posttraumatic stress disorder
Posttraumatic stress disorder (PTSD), the most common psychiatric disorder in veterans, is a chronic disorder, continuing into old age in the majority. With ageing, quiescent PTSD can re-emerge. Various stressors, particularly any symbolic reminder of the original trauma, can trigger or exacerbate PTSD symptoms.
These exacerbations require assertive management. Older veterans benefit from appropriate regular psychotherapy, including trauma-focussed cognitive behaviour therapy or eye movement desensitisation and reprocessing (EMDR), although consideration should be given to cognitive function. Medications commonly used in treating PTSD remain effective, but care in prescribing, to avoid drug interactions and side effects, becomes more important. With ageing, the therapeutic role of meaningful physical, intellectual and social activity increases.
The ongoing impact of PTSD on partners, families and carers should also not be forgotten.
Depressive disorders are a common comorbidity to PTSD, and are common in all elderly. Therefore, they present a potential major problem for the ageing veteran.
Minor depression or dysthymia is a common comorbidity to PTSD in older veterans. This can be disabling, but responds to a combination of pharmacotherapy, psychotherapy and socialisation. Major depressive episodes continue in ageing veterans with PTSD. Suicide is an ever-present danger in depressed older men, including veterans. Treatment needs to be assertive, but allow for physical illness and drug interactions.
Alcohol-related disorders decrease in severity and frequency in ageing veterans, but can remain a significant cause of morbidity and mortality.
Physiological changes with age mean there is less tolerance to the acute effects of alcohol – each alcoholic drink causes a greater increase in blood alcohol and greater impairment, when compared to middle age.
Detoxification is medically more complex and may require an inpatient setting. The long-term use of excessive alcohol can cause multiple medical problems, but most important in old age is alcohol-related dementia.
Drugs which assist specifically with alcohol-related disorders (e.g., naltrexone, acamprosate and baclofen) can be safely utilised in the older veteran.
DVA has developed both alcohol practice guidelines and an online program tailored specifically for veterans with alcohol-related problems.
The most significant psychiatric problem in the elderly is dementia. Currently, approximately 400,000 Australians are suffering dementia. The risk increases with age, and the rate doubles every five years after the age of 65.
There are many types of dementia. The most common in Australia are Alzheimer’s disease and vascular dementia, with other forms (e.g., Lewy-Body dementia, fronto-temporal dementia, and alcohol-related dementia) being less common.
Ageing veterans are at even greater risk of developing dementia. Recent research supports the view that the risk of developing dementia is increased by the presence of PTSD and/or depressive disorders.
For veterans with alcohol-related problems the risk of alcohol-related dementia is significant. Also, given the high rates in veterans of cerebrovascular risk factors there is an increased risk of vascular dementia.
Diagnosing dementia in the presence of pre-existing psychiatric disorders, such as PTSD and depression (which both cause cognitive impairment), is complex and requires specialist expertise with access to neuroimaging (MRI and PET) and clinical neuropsychological testing.
Early diagnosis is essential. There are effective medications that can slow the progression of Alzheimer’s disease. The psychosocial aspects of dementia management are paramount. The burden on carers is enormous and requires specific management.
Expert support and guidance for health practitioners
Given the challenges in an ageing veteran population of accurate diagnosis, and optimising frequently complex management, primary care physicians may benefit from expert support and advice. The DVA Practitioner Support Service is a free nation-wide service offered by Phoenix
Australia with funding from DVA to provide expert multidisciplinary guidance and support to health practitioners, support organisations, and others working with veterans with mental health problems.
Contact the DVA Practitioner Support Service on 1800 VET 777 or via www.phoenixaustralia.org.
Image credit: https://www1.racgp.org.au/
By Richard Bonwick and Geoff Thompson, Consultant Psychiatrists, DVA Practitioner Support Service.