Post‐traumatic stress disorder mistaken for behavioural and psychological symptoms of dementia: case series and recommendations of care

Abstract

In late life, traumas may act cumulatively to exacerbate vulnerability to post-traumatic stress disorder (PTSD). PTSD is also a risk factor for cognitive decline. Major neurocognitive disorder (MND) can be associated with worsening of already controlled PTSD symptoms, late-life resurgence or de novo emergence. Misidentifying PTSD symptoms in MND can have negative consequences for the patient and families. We review the literature pertaining to PTSD and dementia and describe five cases referred for consultation in geriatric psychiatry initially for behavioural and psychological symptoms of dementia (BPSD), which were eventually diagnosed and treated as PTSD in MND subjects. We propose that certain PTSD symptoms in patients with MND are misinterpreted as BPSD and therefore, not properly addressed. For example, flashbacks could be interpreted as hallucinations, hypervigilance as paranoia, nightmares as sleep disturbances, and hyperreactivity as agitation/aggression. We suggest that better identification of PTSD symptoms in MND is needed. We propose specific recommendations for care, namely: clarifying diagnosis by distinguishing PTSD symptoms coexisting with different types of dementia from a specific dementia symptom (BPSD), gathering a detailed history of the trauma in order to personalise non-pharmacological interventions, adapting psychotherapeutic strategies to patients with dementia, using selective serotonin reuptake inhibitors as first-line treatment and avoiding antipsychotics and benzodiazepines. Proper identification of PTSD symptoms in patients with MND is essential and allows a more tailored and efficient treatment, with decrease in inappropriate use of physical and chemical restraints.

PTSD Symptoms and Dementia in Older Veterans Who are Living in Long-Term Care

“…Similarly, family caregivers of Veterans with co-occurring PTSD and dementia have been found to be at greater risk for physical health strain and use more community services compared to caregivers of Veterans with dementia alone (Pinciotti et al, 2016). Many health care providers are also unaware of co-occurring PTSD symptoms and dementia, resulting in a potential for misattribution of symptoms to other conditions (e.g., depression or delirium), which may ultimately result in ineffective treatment strategies, or increased use of antipsychotic medication in Veterans (Bruneau et al, 2020; Cook et al, 2003; Semla et al, 2017).…”

Understanding how Canadian healthcare providers have learned to identify co‐occurring PTSD symptoms and dementia in Veterans

“…agitation) by the individual with dementia in an attempt to communicate their needs or because their needs are unmet (Clifford & Doody, 2018; Hung et al, 2019). Due to this symptom overlap, the influence of PTSD on responsive behaviours can be overlooked, precluding identification and management of symptoms which can result in ineffective care strategies (Bruneau et al, 2020; Cook et al, 2003). For example, increased arousal and hyperreactivity could be mistaken for agitation, resulting in ineffective management strategies or increased use of antipsychotic medication (Bruneau et al, 2020; Cook et al, 2003; Semla et al, 2017).…”

“…Due to this symptom overlap, the influence of PTSD on responsive behaviours can be overlooked, precluding identification and management of symptoms which can result in ineffective care strategies (Bruneau et al, 2020; Cook et al, 2003). For example, increased arousal and hyperreactivity could be mistaken for agitation, resulting in ineffective management strategies or increased use of antipsychotic medication (Bruneau et al, 2020; Cook et al, 2003; Semla et al, 2017). While little is known about the management of co‐occurring PTSD symptoms and dementia, recommended strategies include the elimination or minimization of triggers such as television (Bruneau et al, 2020; Cook et al, 2003).…”

“…For example, increased arousal and hyperreactivity could be mistaken for agitation, resulting in ineffective management strategies or increased use of antipsychotic medication (Bruneau et al, 2020; Cook et al, 2003; Semla et al, 2017). While little is known about the management of co‐occurring PTSD symptoms and dementia, recommended strategies include the elimination or minimization of triggers such as television (Bruneau et al, 2020; Cook et al, 2003).…”

“…Currently, there are no training materials or clinical guidelines available for identifying co‐occurring dementia and PTSD in Veterans in long‐term care (LTC) (Bruneau et al, 2020; Jacobs & Dinoff, 2012; Martinez‐Clavera et al, 2017). Instead, most of the literature consists of case studies describing individual accounts of PTSD symptoms and dementia in older Veterans (Dallam et al, 2011; Ritchie et al, 2019).…”