Palliative Care for Veterans with PTSD by Kehrle, Steckart, Moran

Starting with Dr. Kehrle this started as a research project during training. Case 1 63 yo male sent to radiology for test and became agitated. He was confrontational with staff. He had been a Vietnam Veteran and shared that he had flashbacks when placed on the table for test. He also shared that he was a POW and could not stand to be flat on his back due to pain.

Overview:PTSD, Treatment options, signs and symptoms with special needs of Vets.

PTSD first reports published in 600bc diagnosis of exhaustion in 1800’s, WWII 10% of mobilized men hospitalized between 1942-45. Civil War diagnosis of shell shocked and railway spine. How common is PTSD? 50-90% of people encounter trauma world wide. Lifetime prevalence for Vietnam is 27% female and 35% male.

PTSD classified in DSM 4 as anxiety disorder, develops in some people after extreme trauma. Re-live the event, avoid anything that reminds them of it. Diagnosis is made when all criteria are met in DSM. 6 total expose to trauma, re-experiencing event, persistent avoidance and emotional numbing, Persistant arousal, duration >1month, significant impairment.

Avoidance and numbing: avoid stimuli of trauma, places, behaviors, people that lead to distress. decreased involvement in life activities.

Primary Care PTSD screening: How do we find them before it happens? 4 item screen with yes no answers: do you have nightmares, try hard not to think about it or went out of way to avoid, are consistently on guard, felt numb.

Neuroanatomy: Hippocampus gets stimulated and then awakens with memories, Left amygdala is also involved with feeling at time of trauma.

Neuroendocxrinology: studies have shown decrease levels of glucocorticoid levels with up reg of receptors. Increase central norepinephrine and down reg of receptors. Plasma cortisol levels have been correlated with PTSD, so lower cortisol and PTSD is worse. enhanced HPA axis with negative feedback.

Genetics: increased risk in identical twins, but studies were very small in number.

If you know a vet in crisis 1-800-273-TALK

Treatment options: long term treatment is needed, combined medication and psychotherapy is best, early treatment is better. Psychotherapy is difficult in hospice with vets due to lack of experience with PTSD. Identify mental heatlh professionals with experience to help. Contact VA for help will post how later.

CBT: most well researched approach, gradual reexposure to memories and replace them with healthier thoughts

Stress Management: Cognitive and behavior components, breathing control and relaxation, positive self talk.

Eye Movement desensitization and reprocessing (EMDR) can reduce symptoms in PTSD

VA use CBT and EMDR as first line treatments.

Is PTSD preventable? Pharmacological, Alpha-adrenergic agonist, Bets Blockers, Glucocorticoids, Opiates. These have all been studied in different settings with some results. Vets who received morphine just after event suffered less PTSD.

SSRI’s are most studied class and considered first line with strong evidence for use. SNRI’s have not been studied. Only paroxetine and sertraline have been FDA approved.

TCA’s they decrease flashbacks and nightmares. Generally less tolerated than SSRI’s so not used as first line.

Antipsychotics: possible benefit as adjunct in chronic PTSD. Current large multi-site trial with resperidone. None are approved currently.

Anticonvulsants: effective in restoring emotional stability but none are FDA approved for PTSD.

Benzo’s only 1 study comparing alprazolam with placebo showed small benefit but no evidence they are useful in PTSD and they may be contraindicated in use with CBT.

Future research, NMDA receptor antagonist proposed as possible treatment for distress and depression. Neuropeptide Y signaling may be reduced in PTSD subjects.

2008 20% of vets diagnosed with PTSD from middle east conflicts.

Now back to case study. Patient had suspicious behavior, anxious, nervous and triggered by memories. Could it be delirium? PTSD and dying where the threat to life may mimic original trauma. This can be triggered by life review and lead to poor communication between patient and provider. 1 small study found that 17% of patients treated at VA at end-of-life had PTSD.

1 out of 4 dying Americans are veterans. Currently 23.4 mil Veterans with 5.5 million receiving care at the VA. Must ask to get information because they are there. Veterans are reluctant to disclose PTSD symptoms due to fear and stigmatization. Look for anxiety, substance abuse, avoidance, and attempts to distract with work or activity. Consider using Military History Checklist, “Are you a Veteran?”, provide them opportunity to tell their stories, and THANK THEM FOR THEIR SERVICE! (We live free because they served)

Consider bringing another veteran with you when caring for a Veteran. Try to avoid loud noises, restraints, confining positions, and movies/TV showing war scenes. Goals of care should be to reduce PTSD symptoms.

Family members of patients with PTSD reported overall less satisfaction with care of loved one. all good resources to look at.

I wish that this information had been better known in past as my grandfather had PTSD from serving in WWII but it was not well understood. I only learned long after he died that he served and was wounded in WWII. Great talk and advocacy for Veterans and recognizing PTSD earlier to help them as they die. Without screening for PTSD we will not find it and the Veterans may suffer.

David Wensel

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