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How Will Your Patients Respond to September 11?
by Arline Kaplan
Geriatric Times November/December 2001 Vol. II Issue 6
The woman heard the sirens in the streets as the police cars and fire engines rushed toward the World Trade Center on Sept. 11. Her thoughts flashed back to her childhood in Europe during World War II; she remembered hearing sirens in the streets of her hometown. She paused for some moments and felt sadness as she reflected both on the past bad times and the present tragedy. Then she returned to taking care of her husband's needs and managing his medications.Like everyone else, said Gary J. Kennedy, M.D., president-elect of the American Association of Geriatric Psychiatry and psychiatrist at Montefiore Medical Center in the Bronx, older adults are going to react to the events of Sept. 11. Most of them will recover because they are resilient, and they can rely on their existing family, religious institutions and social support network.
Geriatrician Kenneth Brummel-Smith, M.D., president of the American Geriatrics Society, agreed, telling Geriatric Times, "These are folks who had personal knowledge about Pearl Harbor, the Holocaust and other types of extremely traumatic things happening to them, and they know they have survived them."
Other older people are at increased risk for physical and mental disorders, including some of New York City's 1.3 million residents aged 60 and older. Among Kennedy's older patients are those who have lost family members.
"Older adults are particularly vulnerable to that, because they never expect to lose a child or grandchild," he told GT. "It is not a normative event."
Still other older adults have had to move out of their homes and/or face major disruptions in their care. When the lower part of Manhattan was shut down, Kennedy said, shut-in seniors were in trouble.
"It's not that their housing was destroyed, but their phone lines were disrupted. If you think about it, for seniors who are frail, the critical elements of their care are transportation and communication. So if they can't get out or the caregivers can't get to them, and if they can't use their phone, then it is a disaster waiting to happen," he said.
Since the terrorist attacks, community agencies have been visiting older shut-ins, helping them get needed medications and groceries. Other organizations are donating proceeds from fund-raising events to help address the needs of older adults in New York City.
Neal L. Cohen, M.D., commissioner of the New York City Department of Mental Health, Mental Retardation and Alcoholism Services, acknowledged the needs of the city's older adults in testimony to a U.S. Senate hearing on psychological trauma and terrorism:
The City's Department of Mental Health is already working with the Department for the Aging on a number of projects, including one on age-related depression, and we intend to use this alliance to reach out to older New Yorkers. In particular, we are concerned about maintaining their functional abilities and independent living skills and preventing isolation. Reaching this population will require assertive action by the mental health community. We need to reach out to organizations serving older New Yorkers to insure that face-to-face contact is made.
With regard to older adults throughout the nation, Kennedy urged health care providers to "be alert to the distant effects of this recent event," and to recognize such effects are going to "show up physically as well as emotionally for the older adult."
For example, he said, "Some older patients will skip appointments. This is not a time to just assume that the person will call back and make it up. Health care providers need to be more vigilant and proactive."
According to Kennedy, those especially at risk for suffering anxiety, depression and acute stress syndromes are older Americans who are isolated, dependent, previously traumatized, and have physical or mental disorders.
Published research shows older people's reactions to disasters may include depression, withdrawal, apathy, agitation and anger, irritability and suspicion, disorientation, confusion, memory loss, accelerated physical decline, and an increased number of somatic or bodily complaints (National Institute of Mental Health, 1983, as cited in Oriol, 1999).
Health care providers can expect some older patients to go back to bad habits, Kennedy noted. They may not follow their medication regimens as well as they once did. Some will experience "flare-ups of old conditions that seemed to be well-controlled," he further explained, "and that's going to be a manifestation of stress."
Deirdre Johnston, M.B.B.Ch., assistant professor of psychiatry at Wake Forest University School of Medicine and a geriatric psychiatrist, told GT that physical symptoms, such as headaches, fatigue and sleep disturbances, are common in the aftermath of trauma.
Infections and other types of immune-related problems as well as illnesses such as emphysema and heart disease can increase in older adults during times of stress, said Brummel-Smith, who is director of the Providence Center of Aging for Providence Health System in Oregon.
"When you have emphysema, you have to use a very controlled way of breathing to accommodate for the damage that is going on in the lungs. People who are anxious have difficulty breathing that way, so often there are exacerbations of breathing problems during times of stress…[also] people who have emphysema are more prone to infections [so they get a] double whammy," he explained.
He also explained that anxiety raises the levels of adrenaline and noradrenaline, both of which stimulate the heart. In patients with undiagnosed or poorly controlled heart disease, sudden stress can lead to chest pains and other symptoms or push an individual into heart failure.
Older adults who are already depressed are particularly vulnerable to traumatic events. Emotional stress may induce or intensify depression, especially among those aged 70 and older. Symptoms may be sadness, lack of interest, pessimism and difficulty in making decisions (Administration on Aging, 1994, as cited in Oriol, 1999).
Depression in old age, said Brummel-Smith, is often misdiagnosed, in part because older people tend to express depression differently than younger adults.
"Whereas younger people have prominent emotional symptoms like helplessness, hopelessness and feeling worthless, older people have more prominent physical symptoms…like lack of energy, poor sleep and lack of appetite," he said. "They may say, 'I don't feel depressed,' and they are telling the truth…but they are living depressed, because they have all the bodily symptoms of depression."
Suicidal thoughts, according to Kennedy, are another warning sign that an older person is having a complicated bereavement rather than an acute stress reaction.
Patients who develop signs of a real anxiety or depressive disorder -- not just a symptom or two -- may need help from a mental health care professional, Kennedy said. Some of those signs are lack of self-care, not getting out of the house and not taking life-preserving medications. He added that while psychotherapeutic medications have a role to play in treating anxiety or depression in older adults, they are not the only solution.
"Older patients need a chance to talk about this; we all need a chance to talk about this," he said.
Older combat veterans, political émigrés who have experienced bombings and terrorist activities in their native countries, and others may exhibit an exacerbation of posttraumatic stress disorder (PTSD) symptoms during these exceedingly stressful times.
"Most people who have been in combat or exposed to trauma don't get full-blown PTSD, but some can have partial symptoms. Those people can be troubled by the war news," said Johnston, who is an expert in PTSD and is conducting a wartime experiences and aging study. "A lot of veterans don't admit to war and combat-related symptoms, particularly the older guys…but you may see them riveted to the television. It is better if they get the news and then turn [the television] off."
Johnston is particularly concerned with the effects of Sept. 11 and war news on demented patients. If patients with dementia appear to be more agitated, aggressive or tearful and are experiencing more nocturnal disturbances since Sept. 11, then she recommends that their physicians talk with the patients' families for more background.
"Find out if the patient was a combat veteran, a Holocaust survivor or somebody who lost someone in a war…That would give you a clue that these events are actually distressing them in a personal way and raising their fear level."
For demented or cognitively impaired patients who are distressed by recent events, Johnston said it is important for caregivers to redirect them away from the distressing images on television. In severe cases where the patient with dementia is experiencing depressive and anxiety symptoms, a selective serotonin reuptake inhibitor may be appropriate. For treating increases in aggression, nocturnal disturbances or paranoia, atypical antipsychotics in small doses might be considered.
Johnston emphasized that in institutional settings, staff should particularly monitor the television viewing of cognitively impaired patients. Urging medical directors of nursing homes to pay attention to the use of television to ensure that patients are not being exposed to repeated images of violence and war, Johnston said, "That's not censorship, that is providing a therapeutic environment." She added that television is really not the best company for people who are stuck in a room and cannot turn it off.
"Random, relentless exposure to reminders of a traumatic event without any therapeutic structure, without any outlets for discussion and without any limits to the exposure" can be very harmful to people in general, said Johnston. The experience is even more harmful to those who are cognitively impaired and cannot process the information. For example, during the evening when some demented patients are sundowning, they may not be able to differentiate what is happening on the television from what is happening around them. Currently, many of Johnston's geriatric patients are connecting intensely with the terrorist attacks and the constant war talk on television.
Caregivers of cognitively impaired family members are themselves at risk for health problems during these stressful times, according to both Kennedy and Brummel-Smith.
In discussions with caregivers about their stress, Brummel-Smith asks about their reactions to recent events. In his practice, Kennedy said that for those already overburdened by providing care for a demented spouse, the stress of recent weeks can be the final straw.
Kennedy offered some commonsense recommendations for health care professionals working with older adults seriously affected by Sept. 11 and the ongoing war news. Clinicians need to ask their older patients some questions in a nonthreatening way, such as "How are you doing, given these terrible events?" or "A lot of people are having difficulty coping with all of this, how is it going for you?" These questions open the door in case the person really needs to talk, and their responses give the clinician a sense of whether the patient is symptomatic.
If a referral to a mental health care professional is needed, the clinician might say, "I need help taking care of this problem for you. I know a person who is good with older people and who is not going to treat you like you're crazy, but can help you get over this."
Older adults, Kennedy said, should also be encouraged to make use of other supports, such as religious institutions, as well as to return to their normal routines. He also warned against making things grimmer than they have to be: "We shouldn't lose our sense of humor or joy in life just because we had this terrible moment."
(see Resources for Older Adults) Reference
Oriol W (1999), Psychosocial Issues for Older Adults in Disasters. DHHS Publication No. ESDRB SMA 99-3323. Available at: www.mentalhealth.org/publications/allpubs/SMA99-3323/99-821.pdf. Accessed Oct. 10, 2001.
