Trauma Informed Care with Older Adults
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[00:00:00] Regina Koepp: So often when we think of trauma. Older adults are not the first age group that come to mind. Yet, when we talk about trauma and trauma informed care, it's critical that we're thinking about older adults. And this is because, according to the National Center for Post Traumatic Stress Disorder, Seventy to 90 percent of older adults have experienced a traumatic event in their life.

And older adults are more likely to experience medical trauma than other age groups as well. So we need to be attending to trauma as it relates to older adults, just as we need to be attending to trauma among other age groups. And so today, I'm going to focus on trauma informed care. for older adults.

Often people look at me, they think, oh, you're a geropsychologist, what do you know about trauma?

I want to also just share a little bit of my own professional experience prior to graduate school, I worked at San Francisco Women Against Rape and met sexual assault survivors at the ER, providing them support. Then have had a specialty in trauma as a psychologist at the Grady Healthcare System where I did my postdoc in Atlanta. To the Atlanta VA healthcare system where all of my clients were veterans, many of whom experienced combat trauma, community violence, interpersonal violence, and so on.

And then to medical trauma at the University of Vermont Medical Center. And so my whole career has actually been shaped by not only the traumatic experiences of my clients, but also the healing process and post traumatic growth.

And I cannot underscore that enough. So please check out the show notes for lots of information and resources.

So what's the difference between trauma informed care and treatment for trauma or for PTSD or post traumatic stress disorder? So trauma informed care does not include treatment for trauma directly. While treating trauma includes a biopsychosocial spiritual treatment for healing from the experience of trauma or traumatic experiences and the emotional toll and physiological toll that takes on your body and psyche that can include psychotherapies, that can include psychotropic medications, that can include a whole host of experiences from inpatient trauma treatment to intensive outpatient treatment to once a week psychotherapy and so on.

Trauma informed care does not directly include psychotherapy for addressing trauma. Traumatic events or healing from traumatic events. So they're two separate things. And trauma informed care is really overarching spirit and appreciation and integration of principles in treatment of every individual in health care systems and beyond. And talking about trauma informed care today, I'm going to provide a more comprehensive definition of what trauma informed care is and then what it is specifically and what to consider specifically as it relates to older adults.

Trauma can affect anyone. This can be individuals from every demographic, cultural background, and geographic region. It results from an event or series of events or circumstances that are experienced by an individual.

So let's Just review some trauma basics. I have a lot of different listeners for this podcast, ranging from psychology experts to health aides, to aging services providers, to aging life care experts. And It's really important that we all have a basic understanding of trauma. So this might be a review for you.

If it is, just check it off. Oh yes, I know that.

Trauma. Trauma results from an event or series of events or set of circumstances that's experienced by an individual as physically or emotionally harmful or life threatening and that has long lasting effects on the individual's functioning, And mental, physical, social, emotional, or spiritual well being.

According to SAMHSA and their definition of trauma informed care, there are three E's of trauma. Events, effects and experience. So I'm going to dive into each of these three E's. So trauma is the result of an event.

So events can be one time, like a major car accident, or a tornado, or the wildfires, or a repeated occurrence, like trauma in home or interpersonal violence. They can be experienced individually or collectively. So individually, like in the context of a relationship or collectively, like in the context of a natural disaster.

They can range from something very violent to something catastrophic to also things like community or societal violence or chronic poverty.

[00:05:31] Regina Koepp: And also cultural oppression and discrimination like racism based trauma or LGBTQIA plus phobia. This could also include life threatening neglect, so it doesn't have to be overtly physical.

So now to experience. So what really determines if an event is traumatic is the individual's experience of it. And this is how the individual labels or assigns meaning to the event.

And that meaning informs whether that event is experienced, that's the second E, as traumatic. And so the extent to which the event disrupts physical or psychological functioning will also influence whether it's experienced as traumatic.

And the third E is effects. So effects can be immediate or have a delayed onset. Effects can be short term, like brief, like lasting for only a couple of days, or long term, lasting for years or decades. Effects can be recognizable or seemingly unrelated to the traumatic event.

Effects can be adverse, meaning that they have a negative impact on a person's mental, physical, social, emotional, and spiritual functioning.

And, what we see in up to 50, that's 5 0 percent of older adults, effects can also be constructive, meaning that there can also be post-traumatic growth and resilience.

post traumatic growth is a positive change or outcome following adversity or following a traumatic event. It's a process of restructuring cognitively, spiritually, psychologically, where we might reevaluate our core beliefs, values, and priorities. And researchers have looked at what are the mechanisms for post traumatic growth in people and found five distinct domains in which growth occurs.

One is relating to others. So social connection is key. And we see that everywhere. We see that with health outcomes. We see that with dementia risk reduction. Another domain number two is new possibilities, which I see as hope, like hope for something better, hope for something new, hope for a possibility of healing change and development. Three is personal strength. So believing in our own personal strength and resilience, our fortitude, our ability to move through and withstand this challenge. Number four is spiritual change. And number five is appreciation of life.

These five principles don't happen all at once. It's a dynamic ebb and flow of experience.

So trauma informed care, as I mentioned, is not direct psychotherapy, it's more of a framework for understanding any type of care that's health care, mental health care aging services, resources, adult day center programming, and so on. Any type of care that accounts for the impact of trauma on a person and how that person might be showing up in that care space. And so there are four R's to trauma informed care. The first R is realization. So this is care that realizes the widespread impact of trauma and understands potential paths for recovery. Then it is also care that recognizes signs and symptoms of trauma in clients, families, staff, and within the system as a whole.

A third R is response. So this is care that responds by fully integrating knowledge about trauma into policies, procedures, and practices. And care that resists re traumatization and creates an environment of healing and growth. So trauma informed care is key to providing good care in whatever environment you're working in.

Like I said, from health care to mental health care to aging services to if you're working at an area agency on aging or a state health department, trauma informed care is critical to providing good care for everyone.

So if you'd like more information on trauma informed care for, Older adults, I have a free trauma informed care guide. You can get that guide at mentalhealthandaging. com forward slash T I C for trauma informed care. And I hope that you check it out. It has some great information and resources.

[00:10:42] Regina Koepp: As I mentioned at the start of this, often when we think of older adults, the first condition that comes to mind is not generally trauma. It's generally dementia. And I want to invite you to broaden your perspective of the wide range of experiences that older adults have. And include trauma in your framework for understanding people.

I was at the American Society on Aging conference last year in San Francisco, and I was sitting in on a session. And we were talking about funding. And somebody frustratingly mentioned why does funding always go to children and not to older adults? We need we shouldn't be spending funding on children, we should be spending it on older adults.

And really we need to be taking a whole lifespan approach. Because what happens in childhood, like the access to resources and education, That influences how we age, and it also influences our vulnerability to disease, our vulnerability to dementia disorders, and our longevity. And so we need to be thinking Not just about generations like young adults, children, older adults, we need to be thinking collectively and holistically across the lifespan.

And why am I telling you this as it relates to trauma? Because I want to share with you

a graph on how trauma affects our health

this graph will be on the show notes page. Is from the UCSF Center to Advanced Trauma Informed Care.

I'm going to describe this graph to you and break it down for you. This graph is essentially a triangle. If you imagine a triangle going from the base all the way to the tip, and so at the base, they describe generational trauma.

trauma or historical trauma. And so we see this historical trauma or generational trauma in the form of, history of enslavement Holocaust, things like that. Maybe even family violence and family trauma and this generational trauma, we begin to embody it and gets transferred to us even in the womb from our mother.

That experience, it gets transferred through cells into our body, and then we're born into a social, physical context. And that social and physical context can influence how we begin to heal from that generational trauma. or reinforce the negative effects of that generational trauma.

And so there are conditions that we're born into, like maybe chronic poverty, like we talked about discrimination and bias, maybe interpersonal violence or family violence, maybe community violence. And those experiences are some of the experiences that comprise what's called adverse childhood experiences.

And the more adverse childhood experiences a person has, the poorer their health outcomes. And this is why it's so important that we look at people all throughout the lifespan. And also look at generations all throughout the existence of our nation. And so the more adverse childhood experiences a person has from the age of zero to 18, this can disrupt neurodevelopment, and that can mean neurodevelopment in terms of emotion regulation, in terms of our ability to learn and retain information.

And that then influences our social, emotional, and cognitive development. development or cognitive learning, which also then influences if we have social, emotional, or cognitive impairments. And I'm not at this stage talking about dementia as a cognitive impairment. I'm talking about cognitive impairment in terms of learning, like learning disorders, and inability to encode new information and retain information.

And so what happens then is that with this disrupted neurodevelopment and the social, emotional, and cognitive impairments and challenges, this can create more of a risk for adopting unhealthy behaviors that, like smoking and drinking, and then to manage some of that emotional intensity from a non nurturing environment, and then those behaviors can increase our risk for disease and disability and other problems.

And then when we have higher rates of disease, we have We have risk for early death and poor quality of life. And so really, trauma, and I share this with you because I want to really describe how trauma, even in early life, influences our whole life. And we can change this. And this is why there's so much attention on social determinants of health because when we address social determinants of health, the goal is to reduce the number of adverse childhood experiences or ACEs, they're called, to give everybody the best opportunity for life and work and healthy families and relationships and so on.

And also because that will help our longevity and health in the long run.

I want to also now share some important statistics from the UCSF Center for Advanced Trauma Informed Care. Sharing more about how trauma impacts health. So now that I've described that graph to you and briefly described what adverse childhood experiences are, ACEs, so again, adverse childhood experiences are just that, adverse childhood experiences in childhood from 0 to 18. So things like having a parent with a severe mental illness, having a parent who's repeatedly psychiatrically hospitalized, having a parent who's incarcerated, living in chronic poverty, experiencing violence, experiencing childhood maltreatment and neglect things like this.

And so the more ACEs a person has, the more adverse childhood experiences a person has, I'm gonna share with you, according to UCSF Center for Advanced Trauma Informed Care how this impacts our health. So people with four or more ACEs are 1. 4 times as likely to have diabetes. And diabetes increases our risk for dementia.

Two times more likely to have a stroke or heart disease, which also increases our risk for dementia or cancer. Three times more likely to smoke cigarettes, which also increases our risk for dementia. Three times as likely to have chronic lower respiratory disease. Five times more likely to have major depression.

And let me tell you, major depression is a modifiable risk factor for dementia. 10 times more likely to experience problematic drug use. Problematic drug use also increases the risk for dementia and devastatingly 37. 5 times as likely to attempt suicide. Trauma impacts our health all throughout our life. From the womb to end of life. And so if you're working with older adults, you need to be paying attention. It's really important to get training on trauma informed care and to learn more about what you can do to provide care. A safe, secure, healing environment for the people that you are working with.

Just a couple more statistics on older adults and PTSD. Remember, 70 to 90 percent of older adults have experienced a traumatic event in their life, but the majority of people don't go on to have a diagnosis of post traumatic stress disorder. Only about 1. 5 percent to 4 percent of adults 60 and older have a PTSD diagnosis. And about 7 to 15%, can experience subclinical levels of PTSD. This means that they're experiencing some symptoms of PTSD, but not at the level that would impair functioning.

And, as I mentioned at the beginning, older adults are more likely to experience medical trauma. So here's why. Older adults are more likely to have complex medical hospitalizations, like ICU admissions, which can be terrifying for people.

Hospitalizations may have occurred throughout the older person's life during a less patient centered time. They may have been in the hospital when hospitalizations had longer lengths of stay or prolonged hospitalizations. We know that prolonged hospitalizations are not good for health. There might have been hospitalizations when pain management was less advanced. I was the lead medical psychologist for the medically hospitalized people for a couple of years and one of the trauma events of many people who I worked with who were hospitalized was severe pain from whatever injury brought them into the hospital.

So severe pain from a compound fracture or an open wound that needed acute medical treatment. And the pain was so intense and severe that the person when that when that condition was treated and the pain managed when they would start physical therapy, There was a PTSD reaction to avoiding the physical therapy because I don't want to experience that level of pain again.

There was an avoidance to that level of pain.

Also, it's important to know that older adults who are homebound and receiving home health services are more likely to experience trauma at higher rates. And so if you're working in home health care, it's really important that you receive training on trauma informed care.

And then the final thing that I want to talk with you about today is how PTSD can change with age.

So that's post traumatic stress disorder. I'm gonna link to an article I wrote on differentiating what's normal what are the normal psychiatric responses to a traumatic event that are not problematic.

So after a traumatic event, especially in the days following a traumatic event, It's normal to have distressing memories of the event or distressing dreams or flashbacks or negative mood or altered sense of reality, sleep problems, avoidance symptoms. Three days after the event to one month after the event, if these symptoms are getting in your way of functioning, you might meet the criteria for acute stress disorder.

So not yet PTSD. And acute stress disorder is the period lasting for three days to one month after the traumatic event. And what's important here is that you want to take this seriously and get care and support. If the person is having these symptoms for longer than one month, they might meet criteria for post traumatic stress disorder. And remember, the majority of people don't, but if you're seeing these symptoms, it's really important to reach out to a medical provider and a mental health provider.

And I say medical provider because it's important to make sure that we've also, we're addressing any medical contribution to the psychiatric arousal symptoms. And I'm going to link in the show notes to an article I wrote on what's typical after a traumatic event and the difference between acute stress disorder and PTSD.

And finally, I want to review a little bit more about some unique considerations for older adults With post-traumatic stress disorder, I wanna start by saying that post-traumatic stress disorder symptoms can increase with age or emerge with age, meaning they may have been dormant for decades and then all of a sudden they're here.

And so why is this? There are several things to consider. One is role changes and loss of independence that can make coping with memories of an earlier trauma more challenging. Another is increase in stressors like retirement or health problems or decreased sensory abilities like vision or hearing that can leave a person feeling more vulnerable, maybe reduced income, loss of, death of loved ones, decreased social support and cognitive, increases in cognitive impairment.

These things, these situations can increase the risk for an emergence of PTSD symptoms. And I often will say to older people, sometimes new loss and trauma brings up old loss and trauma. It calls it all into the room. Another consideration is that coping strategies that the person may have used earlier in their life like with work or with even substance use may not be as effective or available now.

Say you retired or say you no longer drink because it is a contraindication with the medication that you're taking. Those coping strategies may no longer be available and so revealing the underlying post traumatic stress disorder.

And also PTSD can be more severe in people with cognitive impairment and dementia disorders. And that's because our emotion regulation system, it's not just our memory that becomes impaired, it's our emotion regulation system and impulse control that becomes impaired too. And so it's really important that if you're working with older adults, And you're aware of a trauma history that you're paying attention.

Alright, I'm saying all of this and encouraging you to get training on trauma informed care. And the good news is that my colleague, Dr. Telsie Davis, and I put together a culturally inclusive trauma informed care program. Just for people working with older adults, and it's actually a certificate program.

We've rolled this out with American Society on Aging. We've trained health systems in this model. It's a six hour certificate program on culturally inclusive trauma informed care with older adults. And I'll link to it in the show notes so you can check it out.

So there's so much that goes into trauma informed care with older adults. I didn't even get into the six core principles of trauma informed care. And like I mentioned, that training will really guide you and your teams in providing trauma informed care to older adults.

Here's what research has found on the benefits of culturally inclusive trauma informed care in healthcare and social services settings. It offers clients and patients the opportunity to engage more fully in their healthcare because they're more fully seen and understood and included in their care.

It helps to develop a trusting relationship with their provider. It improves long term health outcomes. It reduces health inequities. It even helps to reduce burnout among healthcare staff and providers, potentially reducing turnover, and it increases organizational resilience.

So if you'd like more information on trauma informed care for, Older adults, I have a free trauma informed care guide. You can get that guide at mentalhealthandaging. com forward slash T I C for trauma informed care. And I hope that you check it out. It has some great information and resources.

Regina Koepp: There are so many reasons every healthcare system, social services system needs to be providing services. Culturally inclusive trauma informed care. This is just a 30 minute episode. But We dive for six hours into Trauma Informed Care with Older Adults. So I hope that you'll check that out. And share it with your staff. And also if you'd like Dr. Davis and I to present live to your staff, we're happy to do that as well.

Simply just DM me.

Thank you so much for being here. Next week I'm going to talk about vicarious trauma. And this is really important because just as we're talking about our clients experience of traumatic events, clinicians, Traumatic events also experience traumatic events and can experience a vicarious trauma hearing about their clients traumatic events. And so I'm going to share some resources and information about that next week.

Let me know if you'd like a training for your staff.

And I just want to end this episode by saying thank you so much for the work you do.

I look forward to seeing you in the next episode.