Understanding how Canadian healthcare providers have learned to identify co-occurring PTSD symptoms and dementia in Veterans
Accessible Summary
What is known on the subject?
- Little is known about how PTSD and dementia in Veterans is identified by health care providers.
What the paper adds to existing knowledge?
- Healthcare providers identify those behavioural symptoms experienced by older people living with dementia that represent an unmet need associated with PTSD secondary to military service. Once healthcare providers recognize the presence of symptoms relevant to PTSD, they modify their care approach to include focused/tailored non-pharmacological care interventions that address environmental and situational variables that reflect military action.
What are the implications for practice?
- Specialized education and training is needed to improve the identification of PTSD when existent with other co-occurring neurocognitive conditions such as delirium, dementia and depression.
1.1 Introduction
Co-occurring PTSD and dementia in Veterans can be difficult to distinguish from dementia-related responsive behaviours, which may result in inappropriate care management. Improved identification of PTSD and dementia is necessary to inform more appropriate and effective care for Veterans.
1.2 Aim/Question
The purpose of this study was to understand how Canadian healthcare providers have learned to identify the co-occurrence of PTSD symptoms in Veterans with dementia.
1.3 Methods
Eight semi-structured interviews employing the Critical Incident Technique were conducted with key informant healthcare providers who treat Veterans from across Canada. Framework analysis was used to code, sort and develop themes.
1.4 Results
Observed differences in Veterans with PTSD and dementia cued healthcare providers to seek our more information, leading to a new understanding of past trauma underlying the symptoms they observed. Healthcare providers then altered their usual care approaches to utilize trust-based and validation-oriented strategies resulting in more effective care management.
1.5 Discussion
Improvement in the identification of co-occurring PTSD and dementia in Veterans requires specialized education and training for healthcare providers.
1.6 Implications for Practice
Recognizing the complex needs of older Veterans with co-occurring PTSD and dementia is necessary for healthcare providers to implement more effective care for this population.
1.7 Relevance Statement
This paper provides mental health nurses with new understanding of co-occurring PTSD and dementia in Veterans. With an ageing Veteran population in Canada, mental health nurses need to be knowledgeable about the care for Veteran specific mental health needs.
1 BACKGROUND
In older Veterans, co-occurring posttraumatic stress disorder (PTSD) symptoms and dementia (American Psychiatric Association, 2013) can emerge, re-emerge or worsen, resulting in a range of symptoms such as war-related nightmares, physiological hyperactivity, suspicion, aggression and re-experiencing of military trauma (Carlson et al., 2008; Cook et al., 2003; Mittal et al., 2001). Johnston (2000) reported on three cases of combat Veterans who demonstrated increased war-related nightmares, physiological hyperactivity, suspiciousness, violent aggression and anxiety following the onset of dementia. Mittal et al., (2001) described three Veterans who had a worsening of dormant PTSD symptoms, including re-experiencing combat trauma with auditory flashbacks and nightmares following the onset of dementia. Martinez-Clavera et al. (2017) explored two Veterans who had a new onset of intrusive war-related flashbacks, anger outbursts and a fear of hurting others following the onset of dementia. These symptoms may be difficult to manage for healthcare providers and can lead to frustration and burnout (Bruneau et al., 2020; Cook et al., 2003). Identifying co-occurring PTSD symptoms and dementia in Veterans is challenging for healthcare providers (Cook et al., 2003; Martinez-Clavera et al., 2017). Healthcare providers do not routinely receive information about an individual's trauma history and may be unfamiliar with the questions to ask in taking a trauma history (Cook et al., 2003). Although trauma-informed care approaches have been widely implemented across others mental health settings, it remains largely absent from dementia care (Cations et al., 2020). Moreover, the presentation of PTSD symptoms and dementia is difficult to distinguish from responsive behaviours which are commonly experienced by individuals with dementia across all patient care setting (Cook et al., 2003; Martinez-Clavera et al., 2017). Here, responsive behaviours refer to expressions of distress and/or behaviours (e.g. 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). 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). There is a need for research to improve the identification of PTSD symptoms and dementia in Veterans to inform more effective care strategies (Bruneau et al., 2020). The purpose of this study was to understand how healthcare providers in Canadian have learned to identify the co-occurrence of PTSD symptoms in Veterans with dementia.
2 METHODS
2.1 Study design
A qualitative descriptive design (Sandelowski, 2000) employing the Critical Incident Technique (CIT) (Flanagan, 1954) was used. CIT is a highly flexible method where the participant describes a significant care experience in detail including, what led up to the situation, the actions or behaviours of the individuals involved, and the outcomes of the actions or behaviours (Kemppainen, 2000). It is used in qualitative research to provide highly focussed and rich data that can provide solutions to practical problems (Norman et al., 1992; Sharoff, 2008; Wikstrom et al., 2016). This study was conducted as part of a doctoral dissertation and supervised by co-authors are experienced researchers who have experience in qualitative and nursing researchers.
2.2 Participants
Purposeful sampling was used to identify key informants across Canada. Key informants are known as expert sources of information, and they can provide a deep level of insight into a particular situation or issue (Marshall, 1996). Key informants were determined according to the following inclusion criteria: English-speaking healthcare professionals practising in a Canadian setting who had experience working with Veterans with co-occurring PTSD symptoms and dementia.
Two recruitment strategies were used. First, potential participants were identified through the principal investigator's (PI) and supervisors' professional networks, and invitations were emailed to potential participants. Second, the PI contacted administrators of all the Veteran LTC facilities in Canada by email or by telephone and invited them to participate. Inclusion and exclusion criteria were applied and, if participants met study criteria, informed consent was then obtained from all participants who expressed an interest in contributing to the study. Ethical clearance for this study was obtained from Queen's University Health Sciences Research Ethics Board.
2.3 Data collection
The PI conducted semi-structured interviews lasting 35 to 75 minutes with all participants between January and August 2019. A semi-structured interview guide was developed based on findings from a prior scoping review by the authors (Ritchie et al., 2019) and informed by the principles of CIT (Kemppainen, 2000). Interview questions were designed to elicit reflection and a specific description of a critical incident involving the healthcare providers experience in caring for a Veteran with co-occurring PTSD and dementia living in long-term care. Probing questions were then used to explore details in greater depth. Participants were also asked about any prior education or training related to co-occurring PTSD symptoms and dementia. All interviews were conducted by telephone, audio recorded and transcribed verbatim. Anonymized interview transcripts were then uploaded to MAXQDA 2018 (VERBI, 2018).
2.4 Data analysis
Data collection, transcription and analysis occurred iteratively throughout the research process until data saturation was reached (Kerr, 2010). Framework analysis involves familiarization, including identifying a thematic framework, indexing, charting, mapping and interpretation (Ritchie & Spencer, 1994). Familiarization involved reading and re-reading transcripts, along with listening to audio recording to immerse oneself in the data. A thematic framework was developed over 4 months, based on recurrent themes identified in the transcripts, which was then applied to the data and indexed by coding. Charts were devised from key themes found across participants. Themes were compared and checked against the data, for further refinement, and merging where appropriate. The initial thematic framework was reviewed by two investigators, and revisions were made. The emergent themes were reviewed for further refinement and naming by the research team.
Rigour was maintained throughout the study by maintaining field notes and memos as part of the audit trail. In addition, coding queries were run in MAXQDA (VERBI, 2018) to ensure that codes were sufficiently represented across participants. The principal investigator engaged in reflexivity by maintaining a reflective journal to record possible biases and decisions for transparency.
3 RESULTS
In total, eight key informant interviews with healthcare professionals were completed, including three registered nurses, one family physician, one geriatrician, one physical therapist and one social worker. The participants resided across Canada and either worked in or worked with LTC facilities. In total, participants had between 2 and 20 years of experience caring for Veterans with co-occurring PTSD symptoms and dementia. None of the participants had received education or training related to PTSD and dementia. Five themes were identified from the data.
3.1 Theme 1: Recognizing differences in symptom expression
Recognizing differences in symptoms expression was described as the first step in identifying the co-occurrence of PTSD symptoms and dementia. Participants recalled observing a clinical situation in which they noticed something that did not fit with their previous experience of caring for Veterans with dementia. These differences acted as a cue for the participants to look at the situation more critically. This meant that, rather than assuming the difference was part of dementia, they looked further to explore the meaning of the difference.
I guess it was just the behaviors that, ah, we would have identified as responsive behaviors. But then I'm thinking, the responsive behaviors are really, ‘I'm trying to communicate a need,' but in this case it was more around, ‘I'm communicating how I'm responding to this environment, and I don't trust it, and this is scary, and I'm going to p—‘ I'm I think that this symptoms that I saw led him to want to protect himself (HCP 1).
He was—It was like he was, um, always on guard. Right? He was just watching and waiting for something to happen. And then, you know. It, it just was—I, I don't—I'm not explaining it well, but it was just exaggerated. Like, it wasn't your typical… Oh, someone's right there (HCP 8).
…something that, um, you couldn't miss. Right, because it was just quite extreme. So, for example, where he's seated in the dining-room, we make sure that he can -- Like, his back is to the wall. He's closer to the door and he can see – Like, he has a good view of the room. So, just things like that, to make it as comfortable as we can for him.
Q: And did that help?
A: It does, yeah, Like, he – I must say, he still startles, um, but - I would say - from when, when I'm around him, far less. And if, if the, the therapist that he works with – I'm not the one that he comes down and sees in the gym. That's not a day that I'm in the gym. But, from what she says, like, yes, he'll still startle, but it's not a, not a panicked startle anymore. It's like, ‘Oh.' And he, kind of, will smile: ‘I didn't, I didn't see ya coming,' or something like that. Like, it's not a, ah, that he's a,afraid of anything (HCP 8).
… I'll never forget him: his level of fear. And the intensity was, you know, so much higher than any resident with dementia. Like, the intensity of it was so extreme (HCP 2).
… it wasn't until I saw that fear, that he'd literally almost re-located himself to that moment that I was, like, ‘Uh-oh. We have a bit of a bigger problem here than… just dementia with BPSD' (HCP 2).
Participants also described other symptoms they noticed in Veterans with co-occurring PTSD symptoms and dementia, including suspicion, apathy, withdrawal, anxiety, disrupted sleep and low mood. In many of the situations described by participants, a high intensity of emotional state seemed to be present and acted as a cue that something was different in their presentation.
…what we were seeing is: that every month when we run the fire drills, it was catastrophic for him. And so, he ran—We—I, I was on the unit one day that they had actually run one of the fire drills and the alarms went off, ah, and he gathered staff members and, kind of, flipped a table, and had everybody hiding because of the bombing, ah, that was going to ensue, right? (HCP 2).
…fire alarm or a test or something goes off, and, um, he would get very upset and, um, start acting out behaviorally, like screaming, or hitting out. Um, he also gets very upset when people try to – You know, if he doesn't know what you're doing and you, kind of, go up to him and you put - your hands are at somewhere near him, he jumps and will get really upset. And so I, I think that could be related to what he did, um, when he served (HCP 6).
But Veterans, it seems to be that they're having a real deep terror moment, flashback moment. …There's the, there's just that utter fear and terror in their face that just – And you can't touch them Like, there's that jolt (HCP 5).
…they go up to him and a lot of it is, you know, they try to get him to, ‘Come sit down,' but they will, like, use appropriate touch, but that would be okay for someone in dementia that, with dementia that would be angry or upset about something. But not somebody that's, kind of – There's a big difference between anger, and being in, like, the fight-or-flight mode. Because things just react. His body is reacting to his feelings rather than being able to make an understanding. But this person is just trying to help. So, I think, you know: trying to re-direct him in that moment isn't going to help (HCP 6).
Participants noted that trying to use these interventions with Veterans with co-occurring PTSD symptoms and dementia could result in a more extreme reaction, such as physical aggression.
3.2 Theme 2: Seeking additional information to make sense of the difference
Once participants identified that there was something different in their observations of certain Veterans, they took extra steps to seek more information to explain the cause of that difference. They intentionally sought out more information to help them understand the difference in symptom presentation. Participants reported that they were able to tease out relevant information by asking the family questions. In seeking information, participants tried to find out if these symptoms, such as suspicion or nightmares, had been present before. In some situations, family members were aware and able to attribute the symptoms towards previous war experiences. In other situations, families were not aware of symptoms, and participants asked questions about life history and/or military history. Participants noted that, although families were aware of military service, they usually did not know about any traumatic experiences. They noted that few Veterans spoke about the war with their families, “Because I think that's just been the pattern for their life, right? They came home and they didn't talk about it” (HCP 8). In other situations, participants reported knowing that the patient was a Veteran but never considering the possibility that what they were seeing was a function of PTSD symptoms with dementia. The recognition of extreme fear in a Veterans care interaction prompted participants to re-examine life history events and to seek out additional information about military service.
So, this fellow, his pace being wandering, so, ‘They're coming to get me. They're coming to get me. You have to help me.' The rest of the care team is carees [care provider]. ‘Well, you're fine.' ‘There's nobody here' And doing the standard caree [care provider], you know, ‘You're fine.' ‘Don't worry about it.' Walk away and leave him.
But you could see—I could see the anxiety levels coming. And knowing that he was a Veteran and knowing what I know about dementia, I know how the people go back in time. Like, he's a World War II Veteran. Wondering if he's thinking about: he's back on the battle field (HCP 5).
3.3 Theme 3: Taking a different approach to care
A: Um, well, they tried to put their hands, like, on him, but in, like, a friendly way to try and calm him down, or talk to him slowly using, like, a dementia care approach. You know, put their hands out and, ‘It's okay, it's okay,' um, at approaching him, but – And usually, for him, that, when he's angry, mad or upset, that works really well.
A: He gets very -- Um, like, he responds to that well.
Q: Mm-hmm.
A: Um, but in these situations, he doesn't respond.
Q: It's a reassurance they try to give?
A: Yeah, they're trying to reassure him, ah, calm him. Ah, but in these instances, he just, kind of, thrashes out.
Q: Physically, you mean?
A: Physically, yeah.
Q: Did he ever hurt anybody?
A: Oh, yes. Yeah. Many times (HCP 6).
…we're often taught within our health care to re—you know, person-place time, really re-direct, re-orientate. Ah, but knowing that staff really needed to go into his world with him (HCP 2).
…the policy of the unit is, you know, two staff for every person. But you knew that the more people that surrounded him, the more it could trigger his behaviour. And I was able to get him to do for himself, and to perform functionally and cognitively better by just being one-on-one (HCP 1).
…what did work, I think, is the relationship with him. I kind of got a really good relationship with him and his wife. And so, he can recognize me right away. And when he is like that, he will let, like, people that he's very close to—like his wife or he'll let me—kind of help calm him down (HCP 6).
So, I think when you let him realize and take the time to realize that, you know, it's somebody that he knows, that he feels comfortable with, and to go to, then, he can make that link that they're there to help him; not just coming at him (HCP 6).
So, it validates, right? …So, often when we're re-directing and trying to re-orientate we'll increase the behaviors, and arguing with your resident ‘You're at the [B]'. ‘No, I'm not.' ‘Yes, you are.' Um, and then, what it did for him. So, the staff member, you know, were able to get down with him. We were able to hide. Validate: ‘Yuh. No, I'm safe. I'm okay. We're good.' Like, a lot. There's a lot of reassurance through this. ‘We're okay. We're safe.' Not— ‘No, the bomb is not coming,' because you can't convince him of that, right? (HCP 2).
Participants noted that, although these strategies were successful in reducing the intensity of the symptoms, they did not necessarily eliminate them.
3.4 Theme 4: Creating conditions to help others to see the difference
All participants acknowledged the need for additional training for healthcare providers on co-occurring PTSD symptoms and dementia in Veterans. Most participants had received professional development education on responsive behaviours, and a few participants on PTSD in older adults. None of the participants had received education on PTSD and dementia or were aware of this type of education. Helping healthcare professionals to identify PTSD symptoms and dementia requires an increased awareness of the possibility of PTSD associated with dementia in the Veteran population, “so I think what people need is to be exposed to how common PTSD is in Veterans, or—you know, there are people who'll be high-risk groups” (HCP 4).
In addition to knowing about PTSD symptoms and dementia, participants suggested education is required for healthcare providers to make the link between trauma and current symptoms. Learning to use critical thinking when observing symptoms was noted as an essential skill for healthcare providers caring for Veterans to be able to identify PTSD symptoms and dementia. Critical thinking ensures an “individualized approach” (HCP 1) and includes, “always asking yourself the question: what is causing this aggressive behavior?” (HCP 3). This involves knowing the story for each Veteran, “you have to have the time and the patience to understand everybody's story. And that everybody's plan of care is different” (HCP 5). Knowing Veterans' stories helps to inform the types of care approaches that may be successful.
Making this information accessible to all healthcare providers was also identified as a need. Veterans' stories and military experiences may be documented in a history report that is not always easily accessed by staff. Sharing relevant information is needed, so all staff understand the connection between past experiences and current symptoms.
Participants also noted the need to educate healthcare providers about the military, including “language, the terminology, the rank system, the battles” (HCP 5).
It also includes increasing healthcare providers' knowledge of the potential risks and exposures involved in military service, particularly for those in civilian LTC facilities.
So, at the end of the night, you know, just taking those extra bit of time helped settle him down enough that he, eventually, he did go to bed, you know, without the medicine, which was nice. But it's just—Then, then in my role though, I had the luxury of being able to walk with him.
In long-term care, the carers use the best they can with what they have and the resources they have. And unfortunately, the culture is, you know, somebody's restless and agitated, you go to the nurse and you get a PRN until they settle (HCP 5).
In some of the incidents, other healthcare providers observed the same symptoms, but attributed them to dementia, “…the staff often get very caught up in the dementia, and, so they don't always think that other things could be factors” (HCP 6). Focussing only on dementia can contribute to overlooking PTSD symptoms and dementia.
3.5 Theme 5: Self-reflection and learning
…that's always been a part of my practice, but it's definitely—I've amended my practice now. Like, I always have conversations with families, when I'm completing a new referral, to tell me the story… (HCP 2).
Participants described how their experiences of caring for Veterans with co-occurring PTSD symptoms and dementia affected them personally and emotionally. They gained awareness, respect and empathy for Veterans and what they have been through.
I just get frustrated because I can't make changes that I want to change….I just want to go up to the Minister of Health and Veterans Affairs, and like, ‘This is what we're going to do, and you're going to mandate it, and you're going to find the money, and this is how it's going to be.' I just can't do that (HCP 5).
4 DISCUSSION
This study offers important new insights into the care of older Veterans with dementia and PTSD. Identifying co-occurring PTSD symptoms and dementia was found to be difficult due to symptom overlap that tends to obscure differences in symptoms. Another challenge is the tendency of healthcare providers to focus on dementia-related symptoms, rather than the possibility of other co-occurring mental health issues, such as PTSD. Bruneau et al. (2020) notes that, due to the symptom overlap, flashbacks could be interpreted as hallucinations and hyperreactivity as agitation, potentially resulting in the use of unneeded medication. Consequently, considering the possibility of PTSD is an essential part of caring for Veterans with dementia.
Identifying the unique differences in co-occurring PTSD symptoms and dementia was found to be a necessary part of informing the most appropriate and effective care approach. For example, participants in this study reported that they altered their usual care approach after both recognizing the differences in the Veterans' symptom presentation and attributing these differences to PTSD and dementia. Instead, the most successful interventions were building trust between the healthcare provider and Veteran to address fear and/or suspicion. While the necessity of building trust is well established for the care of individuals with dementia, the results of this study suggest that an extra or deeper level of trust is essential for the care of Veterans with PTSD and dementia. It is possible, that for individuals who have experienced trauma, the increased fear creates a greater sense of vulnerability that requires additional efforts on the part of healthcare providers to establish trust and safety. Flannery (2002) also notes that in individuals with dementia, trauma disrupts safety with others that can be restored ensuring caring attachments with care providers. Building trust to foster a sense of safety has also been recognized in Holocaust survivors with dementia living in LTC. Teshuva and Wells (2014) notes that the healthcare providers go to extra lengths to help Holocaust survivors feel safe, due to their vulnerabilities and heightened levels of anxiety and mistrust.
Another effective care approach described in this study was, "going into their world" and required the healthcare provider to specifically validate and address the perceived reality of the Veteran. Instead of reassuring the Veteran of their safety or redirecting them to another activity, this approach required the healthcare provider to specifically acknowledge the perceived danger that the Veteran was experiencing. While similar individualized approaches to validation (Feil, 1992) and personhood (Kitwood, 1997) are well established in the literature on dementia care, the findings from this study suggest validation as a specific and useful intervention for veterans during moments of “reliving" past war experiences. The use of validation in this particular way requires additional research in a greater number and more diverse group of Veterans. Such research could also include validation “scripts” for healthcare providers to use in these moments of reliving past war experiences.
Similarly, co-occurring depression and dementia have been may also go unrecognized and untreated due to symptom overlap, along with the inability of patients to self-report, and a tendency to underestimate the degree of depression (Brown et al., 2009). However, recent improvements in the identification of co-occurring depression and dementia may point to some potentially effective ways to also improve the identification of co-occurring PTSD and dementia. In the last two decades, there is evidence of improvements in identification of co-occurring depression and dementia, by implementing screening of all LTC residents (Beristianos et al., 2016), and additional training for staff (Eisses et al., 2005). Currently, screening tools used for assessing PTSD are difficult to administer when a patient also suffers from dementia because an individual must possess sufficient cognitive ability to respond to questions within PTSD screening tools (Cook et al., 2003). This poses a problem for Veterans with more advanced dementia who have diminished cognitive capacity, leaving clinicians to rely on identification through observations of symptoms and/or behaviours. Establishing an appropriate screening tool could assist healthcare providers to more accurately identify co-occurring PTSD symptoms and dementia.
In this study, none of the participants has received or were aware of any type of specific training or education in co-occurring PTSD and dementia. Developing specialized education and training on co-occurring PTSD symptoms and dementia was strongly recommended for all healthcare providers who care for older Veterans with dementia to improve the identification of co-occurring PTSD symptoms in dementia in Veterans. Cook et al. (2003) also noted that most healthcare providers have received little information about the long-term effects of trauma in Veterans, which can result in mistaking PTSD and dementia for other mental health conditions. Many healthcare providers are also unaware that PTSD can co-occur with dementia. This lack of knowledge has led to a concern that healthcare providers are not currently equipped to manage ageing Veterans entering long-term care with complex conditions, such as the co-occurrence of PTSD symptoms and dementia (Cook et al., 2001, 2003). With an ageing Veteran population, developing a workforce that recognizes the unique and complex needs of older Veterans will be important to meet the future needs of this group (O'Malley et al., 2019). In the United States, efforts have been made to prepare healthcare providers for the unique needs of Veterans with PTSD and dementia. For example, the Department of Veteran Affairs has developed a series of web-based educational resources for healthcare providers caring for Veterans, including one on co-occurring PTSD symptoms and dementia. Academic programs in the United States have also integrated knowledge of Veterans' care into their curriculum for healthcare providers (Randall & Jana, 2017; Ross et al., 2015). Some programs have developed courses dedicated to military and Veteran health or have used simulation to educate students about Veterans' health needs (Cooper et al., 2016). Roe et al. (2019) found that using Veteran-centric simulations improved nursing students' awareness of Veterans' healthcare needs. Additional resources such as these are needed to support healthcare providers in LTC facilities in other countries, including Canada.
5 IMPLICATIONS FOR CARE
While culture change initiatives in dementia care have spread through many long-term care homes in Canada (Dupuis et al., 2016), it is apparent that more education is needed to ensure that care professionals receive education to identify and respond using person-centred non-pharmacological interventions that mitigate the PTSD symptoms experienced by those residents who are Veterans. The findings of this study identify that residents who have served in the military action may be at a higher risk for behaviours that are expressions of their PTSD symptomatology, and thus trust-based and validation approaches should be tailored to address these unique war time experiences. Participants of this study identified that rather than “dismiss” the residents' belief that they might be under attack from an enemy or in the midst of a battle, they found strongly positive outcomes when they acknowledged the fear, and took specific actions that the resident would recognize as safety manoeuvres such as taking cover.
Recognizing and responding to PTSD and dementia in Veterans using this type of validation approach will require a culture shift in care practices. Participants acknowledged that this shift in approach can be difficult for some healthcare providers, and, when combined with a lack of time and shortages of staff, the implementation of alternative approaches is more challenging. It also underscores the necessity to develop additional training and education for healthcare providers to raise their awareness of the possibility of PTSD and dementia when they are caring for Veterans.
5.1 Limitations
Although multiple recruitment strategies were used in this study, some participants who were contacted declined to participate. It is possible that the healthcare providers who opted to participate may not represent the full breadth of perspectives on the identification of PTSD symptoms and dementia in Veterans. While participants in this study were from multiple geographic regions in Canada, the inclusion of participants from all provinces and territories may have allowed for greater transferability of findings. Additionally, it is acknowledged that this study focussed on dementia broadly and did not account for the variations of symptom presentation found in specific types of dementia (i.e. fronto-temporal dementia).
6 CONCLUSION
The Veteran population is increasing in age, resulting in more complex health needs (O'Malley et al., 2019). Co-occurring PTSD symptoms and dementia may not be considered by healthcare professionals who care for Veterans, resulting in the potential for misattribution of all symptoms to dementia. To identify PTSD symptoms and dementia, healthcare providers critically observe differences in symptoms and responses to usual interventions. By understanding the meaning of symptoms, they select interventions focussed on building trust and validating the Veterans reality, instead of usual care strategies for dementia. Improving the identification of co-occurring PTSD symptoms and dementia is essential to inform more effective care approaches. Additional education and training are needed for healthcare providers to be able to distinguish between co-occurring PTSD symptoms and dementia, from dementia alone.
AUTHOR CONTRIBUTIONS
K.R, H.C., A.A., C.D. and C.G contributed to the conception and methodological design of the project. K.R conducted all data collection and drafted the original manuscript. K.R. and H.C. conducted data analysis and interpretation. All authors reviewed and made revisions.
ETHICAL APPROVAL
Ethical clearance for this study was obtained by Queen's University Health Sciences and Affiliated Teaching Hospital Ethical Review Board #6023426.
Open Research
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
