The number of veterans aged ≥ 65 years is expected to increase steadily as the Vietnam-era cohort ages. In 2012, the number of veterans aged ≥ 85 years was expected to peak at nearly 1.4 million. Vietnam-era veterans comprise the largest cohort of veterans, and > 15% of male and > 8% of female Vietnam veterans receiving care in the VA system have been diagnosed with posttraumatic stress disorder (PTSD). These veterans are rapidly approaching age groups in which cognitive disorders increase exponentially in prevalence.
Combat exposure has been called a common but “hidden variable” in studies of aging and health. 1 Combat exposure may be even more hidden for Vietnam veterans who have pursued health care outside the VA system and less likely to announce their service to health care providers.
Even veterans who did not serve in traditional combat roles can experience chronic debilitation from the psychological stress of overseas deployment to a war zone. Indeed, cases of noncombat trauma have been presented in the context of cognitive decline and late-onset PTSD. 2 It is probable that survivors of sexual assault, child abuse, crime, and natural disaster are also vulnerable to a recurrence of trauma symptoms if they experience cognitive slippage. In this article the authors report a case of delayed onset PTSD symptoms, precipitated by cognitive decline.
Case Report
Mr. B was a 72-year-old Korean War veteran referred for neuropsychological evaluation to establish baseline cognitive status before elective cardiac surgery. Mr. B relied on his wife to fill in many details of his personal history. His wife reported that the patient’s memory problems had increased significantly over the previous 12 months. Mr. B had been treated with donepezil 10 mg daily for about 1 year, with no observed benefit. His wife described life at home as “tense” due to his increased irritability and poor insight into his condition. Mr. B reported that he was often afraid of noises at night and needed to go outside and look around. His wife reported that he was very afraid of “strangers coming into the house.”
Mr. B was born in Arizona and experienced significant physical abuse while under the care of an alcoholic foster parent. He dropped out of high school and enlisted in the U.S. Marine Corps. Upon his discharge from military service, he worked as a truck driver for 23 years. He retired after experiencing hip problems. He drank heavily for many years after the war and, according to his wife, was “very violent,” but stopped 27 years previously, after injuring his wife while intoxicated. The patient’s medical history included hospitalization about 1 year prior to the evaluation following a fall associated with altered level of consciousness and confusion, which lasted several hours. He was discharged the same day and was thought to have had a stroke. The patient also had hypertension, hyperlipidemia, and sciatica. A carotid ultrasound showed bilateral carotid stenosis > 50%.
Mr. B was married for 45 years and had 5 children and 12 grandchildren. He enlisted in the U.S. Marine Corps at age 19 and served as a tank gunner during the Korean War. He experienced extremely heavy combat, was wounded several times (including loss of consciousness due to an explosion), and was hospitalizedfor 4 m onths in Japan. When he returned to the frontline, he found that many of the men in his unit had been killed. He was promoted to staff sergeant and tank commander. Mr. B received an honorable discharge after the war and a 50% service-connected disability pension for PTSD. He reported having received group psychotherapy at a VA hospital soon after the war but no other psychiatric treatment. He avoided watching the news because the Gulf War news reminded him of Korea.
Mr. B was smiling, pleasant, and cooperative throughout the 2 hours of testing and interviewing. He wore a Korean War veteran baseball cap festooned with military pins and ribbons, including a Purple Heart ribbon that he proudly showed to the test administrators. Unbidden, he also presented for inspection an assortment of life membership cards in various veterans service organizations. Mr. B reported frequent nightmares, night sweats, and intrusive thoughts about his combat experiences. During testing, he was repeatedly triggered by innocuous items and launched into a discourse on his combat experiences. When asked to memorize a short list of words that included the word fire, he said, “You know what that reminds me of...we had to fire big guns, 90 millimeter, that’s what it was…killing and how to kill.” When shown an abstract design that resembled the number 44, he said, “You know what that is? It was the radio call sign of our tank—‘This is 44, come in, we need some help.’”
Mr. B’s memory problems were marked by rapid forgetting, impaired ability to learn new information, and impaired ability to recall previously learned information. Language problems were also present, including difficulty recognizing and naming common objects, impaired auditory comprehension, and problems with verbal associative fluency during timed tasks. He also showed difficulties with executive functioning, attention, and working memory. His mini-mental state examination score was 21/30. He stated the year was 2020, did not know the day of the week, registered 2/3 words and recalled 0/3, he counted 3/5 in serial 7s, and was unable to repeat the phrase, “no ifs, ands, or buts.”
Discussion
Posttraumatic stress symptoms were present during the immediate aftermath of the initial trauma exposure for this patient. He managed to lead a relatively successful and productive life, sustained a marriage, and raised a family. The onset of cognitive decline precipitated a recrudescence of PTSD symptomology. In fact, the effects of combat trauma seem more malignant and extreme at the time of the memory disorders evaluation than at any prior time in his life.
A number of case reports have been published in recent years that describe comorbid presentations of cognitive disorder and PTSD symptomatology. 3-6 A clinicalconsensus that cognitive decline can exacerbate previously well-managed symptoms of earlier psychological trauma seems to be emerging. Several published casestudies have noted that comorbid presentation of dementia and PTSD is often marked by violence, psychotic symptoms, and increased risk of hospitalization. 7-9
PTSD Research
Unfortunately, systematic investigation into the