NOELLE FIELDS, MSWLYNN DOBB, MA

KEITH ANDERSON, PHD

College of Social WorkThe Ohio State University

April 15, 2011

Presentation for the Ohio Association of Gerontology Education

Understanding and Identifying Past Trauma in Newly Admitted

Nursing Home Residents

Life is an onion and one cries when peeling it.

~Proverb

Background: Trauma

At its core, trauma is an extreme form of stress- an event or situation that taxes or exceeds adaptive and coping resources (Lazarus & Folkman 1984)

Multiple forms of traumaSequelae-acute or long term, horror,

helplessness, chronic symptoms, anxiety , hyper –vigilance, social isolation and somatic disorders (APA, 1994)

Onset variable (Averill & Beck, 200, Davison et al., 2006, Yehuda et al., 2009)

Background: Aging and Trauma

Aging can erode coping abilities and resources resulting in vulnerability for older adult with early life trauma (Aarts & Op Den Velde, 1996; Graziano, 2003)

Little symptomatology early years- later manifestations of symptoms (Falk, Herson, & Van Haslet, 1994 )

Losses associated with aging increase difficult to repress or compartmentalize memories of past trauma (Averill & Beck, 2000)

Background: Aging and Trauma

Late Onset Stress Symptomology (LOSS) subclinical level distress caused by later-life reactions to early-life trauma

Post-Traumatic Stress Disorder (PTSD)- significant distress or impairment in social, occupational or other important areas of functioning (APA, 1994)

Cascade effect –lasting impact of early trauma plus accumulation of stressors and losses associated with aging and deleterious outcomes in later life (Hyer & Sohnle, 2001)

Who Does This Impact?

Individual -Triggers- events that cause emotional and behavioral reactions exacerbating symptoms of LOSS or PTSD

Family Caregivers – Stress Process Model- caregiving as a set of stressors

Professional Caregivers- Challenges for non-familial care providers (Ammerman, 2006)

Newly Admitted Nursing Home Residents

Past trauma can re-emerge or be exacerbated in later life A significant portion of the general adult population

has experienced at least one traumatic event (Kessler et al., 1995)

Re-emergence of past trauma can impact: receptiveness to care reactions to environmental and situational triggers

Are social workers and other health care personnel in the nursing home adequately assessing and accounting for past trauma in their resident assessments?

Minimum Data Set (MDS)

Mandated, government-developed assessment tool used in almost every nursing home in the United States (Centers for Medicare and Medicaid Services, 2010)

Does not include any specific components related to a resident’s history of trauma

one single item intended to code for an active diagnosis of PTSD

Other sections within the MDS relate to a resident’s: Mood Behavior Preference for daily routine

Psychosocial Assessment

Completing a comprehensive social history is a part of establishing a resident’s plan of care (Beaulieu, 2002)

o trauma history is not necessarily a part of a resident’s social service history

• Asking the question…has the individual has experienced trauma during her or his lifetime?

Other Considerations

Willingness to share information reluctance given the sensitive nature of this

information Trusting relationship/s, rapport

Support and discussion of past traumatic events are typically part of the course of treatment for trauma-related problems such as PTSD (Kaplan & Sadock, 1998).

Case Study Illustration Mrs. C. is an 86-year-old woman who was admitted to the nursing

home for long-term care after a hospital stay for a broken hip. While in the hospital, Mrs. C became increasingly debilitated and was unable to be discharged to her apartment in the community due to her inability to manage her own care needs. Mrs. C also demonstrates mild to moderate symptoms of memory impairment related to her diagnosis of dementia. Upon admission the nursing home, the attending nurse completes the initial nursing assessment which includes primary diagnoses, prescribed medications, and other pertinent medical information for Mrs. C’s chart. She notices that Mrs. C becomes anxious at times during the assessment, especially when completing a brief physical exam. The following day, the nursing home social worker meets with Mrs. C and gathers basic psychosocial history (e.g. marital status, work history, social supports) and information relevant for MDS and care plan documentation. The social worker notices that Mrs. C has difficultly recalling information and expressing her care needs so she decides to contact her daughter who is also listed as her durable power of attorney. During a brief phone call with Mrs. C’s daughter, the social worker is only able to gather a limited amount of information, thus she relies on a review of Mrs. C’s medical chart to complete the remainder of her psychosocial assessment.

Case Study (cont.) Over the course of the next several weeks, Mrs. C

demonstrates increasingly agitated behaviors, including resistance to staff during assistance with personal care as well as fears toward other nursing home residents and staff, particularly men. She is especially fearful at night, often yelling out for help when the lights in her room are turned off and the door is closed shut. Nursing home staff also reports that Mrs. C becomes combative at times when she is being helped with dressing and undressing. According to her MDS and care plan, Mrs. C’s behavior manifest as a result of her diagnosis of dementia. The nursing staff has ordered a psychiatric consult to see if medications might be address Mrs. C’s heightened anxiety. One month following admission and after several family care conferences, Mrs. C’s daughter finally reveals that Mrs. C was sexually abused as a young woman and that these challenging reactions to the nursing home environment may be related to this early-life trauma.

Case Study: Discussion

Impact of incomplete or inaccurate information

Resident adjustment

Resident care planning

Family caregiver stress

Importance of Early Screening

Implementation of psychosocial interventions rather than medical interventions

Identifying and reducing or removing triggers

Staff approaches to care

Conclusions

Current nursing home assessment tools fail to specifically ask about past trauma

Awareness of the special challenges in caring for aging trauma survivors

Proactive approach in assessing for past trauma

Value of asking the question…

Questions?