The Prevalence of Lifetime Trauma and Association with Physical and Psychosocial Health Among Adults at the End of Life

Kate A Duchowny; Alexander K Smith; Irena Cenzer; Chelsea Brown; Grace Noppert; Kristine Yaffe; Amy L Byers; Carla Perissinotto; Ashwin A Kotwal

doi:10.1111/jgs.19209

. Author manuscript; available in PMC: 2026 Jan 1.

Published in final edited form as: J Am Geriatr Soc. 2024 Oct 1;73(1):123–135. doi: 10.1111/jgs.19209

The Prevalence of Lifetime Trauma and Association with Physical and Psychosocial Health Among Adults at the End of Life

Kate A Duchowny ¹, Alexander K Smith ^2,³, Irena Cenzer ^2,⁴, Chelsea Brown ⁵, Grace Noppert ¹, Kristine Yaffe ^3,^4,^6,⁷, Amy L Byers ^2,^3,⁶, Carla Perissinotto ², Ashwin A Kotwal ^2,³

PMCID: PMC11735274 NIHMSID: NIHMS2024719 PMID: 39353852

Abstract

Background:

National guidelines recognize lifetime trauma as relevant to clinical care for adults nearing the end of life. We determined the prevalence of early life and cumulative trauma among persons at the end of life by gender and birth cohort, and the association of lifetime trauma with end-of-life physical, mental, and social well-being.

Methods:

We used nationally-representative Health and Retirement Study data (2006-2020), including adults age >50 who died while enrolled (N=6,495). Early-life and cumulative traumatic events were measured using an 11-item traumatic events scale (cumulative trauma: 0-5+ events over the lifespan). We included 6 birth cohorts (born <1924; children of depression (1924-1930); HRS cohort (1931-1941); war babies (1942-1947); early baby-boomers (1948-1953); mid-baby boomers (1954-1959)). End-of-life outcomes included validated measures of physical (pain, fatigue, dyspnea), mental (depression, life satisfaction), and social (loneliness, social isolation) needs. We report the prevalence of lifetime trauma by gender and birth cohort and the adjusted probability of each end-of-life outcome by trauma using multivariable logistic regression.

Results:

The mean age at death was 78 years (SD=11.1) and 52% were female. Lifetime trauma was common (0 events: 19%; 1-2: 47%; 3-4: 25%; 5+: 9%), with variation in individual events (e.g. death of a child, weapons in combat) by gender and birth cohort. After adjustment, increasing cumulative trauma was significantly associated (p-value<0.001) with higher reports of end-of-life moderate-to-severe pain (0 events: 46%; 1-2 events: 50%; 3-4 events: 57%; 5+ events: 60%), fatigue (58%; 60%; 66%; 69%), dyspnea (46%; 51%; 56%; 58%), depression (24%; 33%; 37%; 40%), and loneliness (12%; 17%; 19%; 22%), and lower life satisfaction (73%; 63%; 58%; 54%).

Conclusion:

Older adults in the last years of life report a high prevalence of lifetime traumatic events which are associated with worse end-of-life physical and psychosocial health. A trauma-informed approach to end-of-life care and management of physical and psychosocial needs may improve a patient's quality of life.

INTRODUCTION

Patients experiencing serious, life-limiting illness and their families can experience a greater burden of physical, psychological, social, and spiritual needs in the years leading up to death.¹ To address these needs, there is a growing recognition that clinicians should account for prior traumatic events as these events may exert profound impacts on a person’s well-being at the end of life.^2,3 The 2018 National Consensus Project for Quality Palliative Care, for example, discusses the importance of recognizing and addressing trauma across physical, psychological, social, spiritual, and cultural aspects of end-of-life care.⁴ Yet, among those at the end of life, little is known regarding the epidemiology of trauma, and how prior life trauma is related to these different domains of end-of-life well-being.

Extensive prior literature suggests that life stage, gender, and birth cohort may all contribute to variable exposure to trauma over the lifespan and its impact on health outcomes. For example, traumatic events in early life (<18 years old) can have reverberating consequences throughout the life course, influencing a range of outcomes including inflammatory gene expression, social and emotional isolation, poor health behaviors, and an increased risk of experiencing other traumatic events.^5-9 Individuals belonging to distinct birth cohorts and gender may have different exposures to military service or access to medical advances (i.e. maternal health and infant/child mortality).

There are several reasons the health effects of lifetime trauma require separate examination among people in the last years of life. Serious illness may itself be traumatic, ranging from hospitalizations and ICU stays, to the emotional distress of a new, life-threatening diagnosis such as cancer;² this medical trauma might trigger memories or emotions related to earlier trauma, making the overall psychological impact of their end-of-life serious illness more severe. In addition, physical and psychosocial symptoms such as pain, depression, and loneliness are more common at the end of life due to new serious illness, end-stages of chronic illness, and progressive frailty or functional decline.^10-13 Trauma may therefore play a different role in exacerbating symptoms or coping strategies compared to earlier in life. Moreover, the study of trauma and end-of-life symptoms can inform clinical frameworks for trauma-informed palliative care. These frameworks were developed from literature from earlier in life and clinical experience, with little empirical data drawn from people with serious illness or approaching death .^3,14-20 A better understanding of the relationship of trauma to different domains of end-of-life well-being could help tailor trauma-informed palliative care strategies such as life review, legacy sharing, and even careful re-engaging with trauma in efforts to improve meaning, coherence, and spiritual well-being.^3,14-20

The primary objectives of this study were therefore to leverage a nationally-representative cohort of older adult decedents to determine: 1) the prevalence of early-life and cumulative trauma among older adults at the end of life by gender and birth cohort, and 2) the relationship of early-life and cumulative trauma with physical symptoms, mental health, and social well-being at the end of life.

METHODS

Study sample

Study data comes from the Health and Retirement Study (HRS), a nationally-representative cohort of adults aged 51+ years who are interviewed biennially until death.²¹ Beginning in 2006, the HRS investigators administered a comprehensive “Psychosocial Leave-Behind Questionnaire” (LBQ), which asked participants about whether they experienced individual traumatic events and assessed other aspects of their psychosocial wellbeing. The HRS also includes an “Exit Interview” for decedents which asks proxies about symptoms experienced by the enrollee in the last year of life. Study information has been described in detail elsewhere.²²

Our study cohort was composed of HRS participants who died between 2006 and 2020.¹¹ Among the 9,897 HRS decedents who died after 2006, our main analytic cohort included 6,495 decedents who had at least one LBQ measure between 2006-2012 with data on traumatic events. Analyses involving “Exit Interview” data on physical symptoms were available for a subset of 5,303 decedents, and completed LBQ data on psychosocial measures within 4-years of death was available for a subset of 3,965 decedents. See Supplementary Figure 1 for the sample flow derivation.

Exposure

Trauma was assessed using a previously published 11-item traumatic events scale; this asked about traumatic events experienced in one’s lifetime (yes/no) and the year at which each of these occurred.²³ Traumatic events were included in this scale based on prior literature, traumatic events listed in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), and previous studies’ reports of commonly experienced traumatic events.²³ Examples of traumatic events included: “Has a child of yours ever died?,” “Did you ever have a life-threatening illness or accident?,” and; “Have you ever been in a major fire, flood, earthquake, or other natural disaster?” The full list of questions pertaining to traumatic life events are presented in Supplementary Table 1. We note that these events may have variable impact for different individuals, and have been referred to as “potentially traumatic life events,” early life adversity, and stressors in prior literature; we refer to them as traumatic events for simplicity and consistency with original scales. We created two measures of potentially traumatic events: (1) Cumulative trauma, defined as the count of total traumatic events experienced across all life stages (range: 0–5+); and (2) Early life trauma, the sum of traumatic events occurring before the age of 18 (range: 0-3+), given a well-established literature that has repeatedly demonstrated the distinct consequences of trauma experienced during childhood.^24-26 In our study sample, the vast majority of traumatic events (>95%) reported occurred >5 years prior to death including prior experiences of serious illness (98.7%), which was assessed using the date of death and the dates in which the traumatic events occurred.

Outcomes

We examined three domains of end-of-life health outcomes using a combination of proxy and self-reported responses. First, physical symptoms included pain, fatigue, and dyspnea drawn from the “Exit Interview” administered to proxies after an HRS respondent’s death. Proxies were asked if the HRS decedent had “at least one month in their last year of life” where they had moderate-to-severe pain (two part question asking if decedents experienced pain and if it was typically “mild, moderate, or severe”), dyspnea (described as “difficulty breathing”), or fatigue (described as “severe fatigue or exhaustion”). Second, mental health outcomes were self-reported by respondents within 4 years prior to death, and included depressive symptoms and life satisfaction. Depression was determined using the 8-item CES-D scale in the HRS core survey, with depression defined as three or more depressive symptoms (≥3 points on 0-8 scale).²⁷ Life satisfaction was measured using a five-item scale in the LBQ (Range: 5-35 points; 20+ points corresponding to high life satisfaction). ²⁴ Third, social well-being outcomes were self-reported by respondents within 4 years prior to death, and included loneliness and social isolation. Loneliness was defined based on the UCLA 3-item questionnaire (≥7 points on 3–9 scale),²⁸ and social isolation defined using a previously published 0-6 point scale measuring household contacts, social network interaction, and community engagement, with 0-2 points corresponding to social isolation.^11,29,30

Covariates

The following hypothesized confounders were included in our analysis: age, self-reported gender (man/woman), self-reported race (Black, white, Hispanic non-White, Hispanic non-black) and ethnicity (Hispanic), and childhood socioeconomic status, a previously validated, multidimensional indicator that captures one’s socioeconomic status in early life.³¹ These covariates were chosen since we could be confident they preceded our main exposure and were therefore not on the causal pathway. Other major correlates of physical, social, and mental health, the outcomes included in this study, were not included because they are potentially influenced by trauma experienced early in the life course, and therefore mediators on the pathway.^26,27

In addition, we included birth cohorts based on the respondents’ birth year since individuals of similar age at death may have vastly different exposures to trauma depending on birth year. Based on the recommendations of the HRS, six birth cohorts were included: AHEAD (born <1924), Children of the Depression (CODA, 1924-1930), HRS (born 1931–1941), War Babies (born 1942–1947), Early Baby Boomers (born 1948–1953), and Mid-Late Baby Boomers (born 1954–1965).²¹

Analytic strategy

We first present overall prevalence estimates of trauma and differences in trauma by demographic and health characteristics; differences were assessed using STATA survey procedures based on t-tests for continuous variables and Rao chi-square tests for categorical variables. We then report the age-adjusted prevalence of trauma stratified by gender and birth cohort derived from regression models. We next employed logistic regression to determine the association of trauma with the three health domains of interest. As described above, we employed a parsimonious model strategy that only included potential confounders, and not mediators on the causal pathway, in order to avoid over adjustment.³² Analyses were conducted using Stata 18 and were weighted using HRS leave behind sampling weights to account for non-response and the complex survey design.

RESULTS

Sample characteristics

Among the 6,495 decedents included in this study, 52% were women and the mean age at death was 78 years (SD= 11 years). 83% percent identified as non-Hispanic white, 9% as non-Hispanic Black, and 5% as Hispanic ethnicity. The majority (81%) reported having experienced a traumatic event at any point in the life course. Almost half (47%) reported experiencing 1-2 events, 25% reported 3-4 events, and 9% reported 5 or more events, with similar overall prevalence across gender, race and ethnicity, and socioeconomic status (Table 1; Supplementary Figure 2).

Table 1.

Characteristics of the Health and Retirement Study Sample (N=6,495)

		Overall	Cumulative trauma events (range 0-11)¹
			0	1-2	3-4	5+
		N=6,495	N=1,229 (18.8%)	N=3,086 (46.9%)	N=1,646 (25.1%)	N=534 (9.2%)	p-value
Age (SD)		78.4 (11.0)	79.4 (11.1)	78.9 (10.8)	78.4 (10.7)	74.3 (11.4)	<0.001
Gender	Men	3,024 (47.6%)	482 (38.8%)	1,397 (46.2%)	854 (53.8%)	291 (56.0%)	<0.001
Gender	Women	3,471 (52.4%)	747 (61.2%)	1,689 (53.8%)	792 (46.2%)	243 (44.0%)	<0.001
Race and ethnicity	White	4,996 (83.4%)	882 (78.6%)	2,390 (84.1%)	1,320 (86.5%)	404 (81.0%)	0.001
	Black	944 (9.3%)	219 (12.5%)	427 (8.5%)	218 (8.2%)	80 (9.5%)
	Latino/Hispanic	439 (5.3%)	101 (6.9%)	215 (5.3%)	85 (3.6%)	38 (6.5%)
	Another Race	116 (2.0%)	27 (2.0%)	54 (2.0%)	23 (1.7%)	12 (3.1%)
Married or partnered	No	3,691 (56.8%)	708 (57.9%)	1,765 (57.5%)	900 (54.3%)	318 (58.2%)	0.30
Married or partnered	Yes	2,801 (43.2%)	520 (42.1%)	1,319 (42.5%)	746 (45.7%)	216 (41.8%)	0.30
Education >HS	No	2,081 (29.1%)	416 (31.0%)	943 (27.2%)	515 (28.2%)	207 (37.0%)	<0.001
Education >HS	Yes	4,413 (70.9%)	813 (69.0%)	2,143 (72.8%)	1,131 (71.8%)	326 (63.0%)	<0.001
Wealth/Assets³ (Median; IQR)		117,000 [13,150-369,000]	135,000 [14,300; 412,000]	133,000 [20,300; 400,000]	113,881 [16,000; 353,000]	40,000 [800; 173,000]	<0.001
Self-Reported Health	Excellent	191 (2.9%)	47 (3.8%)	101 (3.1%)	35 (2.3%)	8 (1.4%)	<0.001
	Very Good	871 (13.8%)	185 (16.0%)	449 (14.9%)	180 (11.6%)	57 (9.4%)
	Good	1,690 (26.6%)	354 (29.3%)	825 (27.4%)	400 (24.8%)	111 (21.6%)
	Fair	2,066 (30.9%)	374 (29.7%)	958 (30.5%)	566 (32.7%)	168 (31.0%)
	Poor	1,665 (25.8%)	267 (21.1%)	748 (24.1%)	463 (28.6%)	187 (36.6%)
Medical Conditions	High Blood Pressure	4,926 (74.4%)	915 (72.5%)	2,341 (74.2%)	1,266 (74.9%)	404 (77.5%)	0.33
	Diabetes	2,196 (32.9%)	343 (28.1%)	1,058 (32.7%)	591 (34.3%)	204 (40.2%)	<0.001
	Cancer	2,034 (31.2%)	298 (23.1%)	950 (30.8%)	575 (35.4%)	211 (38.2%)	<0.001
	Lung Disease	1,525 (24.0%)	202 (16.7%)	653 (21.7%)	467 (27.9%)	203 (39.6%)	<0.001
	Heart Disease	3,305 (49.5%)	467 (36.6%)	1,552 (48.9%)	963 (56.6%)	323 (59.6%)	<0.001
	Prior Stroke	1,529 (22.4%)	248 (19.7%)	704 (21.1%)	422 (24.7%)	155 (27.9%)	0.010
Sensory Impairment	Vision Impairment	2,512 (37.6%)	449 (36.2%)	1,164 (36.2%)	661 (38.9%)	238 (44.3%)	0.023
Sensory Impairment	Hearing Impairment	2,382 (36.2%)	417 (33.3%)	1,087 (34.6%)	667 (40.3%)	211 (39.7%)	0.001
Functional Impairment	Incontinence	2,540 (39.3%)	410 (33.8%)	1,195 (39.0%)	678 (41.5%)	257 (46.1%)	<0.001
	Bathing	1,708 (24.5%)	332 (25.7%)	809 (24.5%)	434 (25.1%)	133 (20.2%)	0.194
	In/out of bed	1,019 (14.6%)	209 (16.6%)	470 (13.6%)	252 (14.4%)	88 (15.8%)	0.192
	Dressing	1,587 (22.5%)	301 (22.4%)	755 (22.5%)	405 (22.8%)	126 (22.7%)	0.996
	Eating	764 (10.7%)	158 (12.0%)	369 (10.5%)	173 (10.3%)	64 (10.2%)	0.588
	Toileting	810 (11.5%)	171 (12.6%)	393 (11.9%)	183 (10.4%)	63 (10.0%)	0.242

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Abbreviations: SD – standard deviation; HS – High School; AHEAD - Asset and Health Dynamics among the Oldest Old; CODA – Children of the Depression Age, HRS – Health and Retirement Study; Estimates are derived from regressino models adjusting for age. P-values were determined using Wald tests. Percentages are column percentages; ¹cumulative trauma is defined using an 11-item scale (Krause et al. 2004); ²Birth cohorts defined based off HRS recommendations; ³Wealth/Assets was calculated as sum of all assets minus the sum of all debts

Age-adjusted prevalence estimates of traumatic events by gender and birth cohort

The distribution of cumulative traumatic events was similar by gender (Supplementary Figure 3A). Nearly 40% of individuals experienced trauma before 18 years of age (“early life trauma”), with higher overall prevalence for men (44%) compared to women (35%) (Supplementary Figure 3B). We also observed gender differences by the type of traumatic events (Figure 1); for example, women were more likely to report the death of a child (women: 24% vs men: 18%, p<0.001), while men were more likely to report firing a weapon or being fire upon in combat (men: 23% vs. women: 1%, p<0.001). The most common traumatic event reported was having a prior life-threatening illness (47% of men and 38% of women); prior life-threatening illnesses in our sample typically occurred >5 years prior to death (87%).

Figure 1. — Adjusted probabilities are derived from multivariable logistic regression adjusting for age and gender. Asterisks in the x-axis denote a significant difference in prevalence by gender (p<0.05), and error bars represent 95% confidence intervals.

After stratifying by birth cohort, compared to individuals belonging to younger cohorts, those in earlier generations (born before 1941) more commonly reported deaths of children (23- 26% vs 11-15%) and spouses or children having a life threatening illness (36-39% vs 20-29%) (Table 2). Firing weapons (or being fired upon) in combat was common across several generations (11-15%), with the exception of mid-late Baby Boomers (4%) and the HRS cohort (7%). Early life traumatic events were generally more common among later generations.

Table 2.

Age adjusted prevalence of traumatic events by birth cohort

	Overall	Birth Cohort
		AHEAD	CODA	HRS	War Babies	EBB	MBB	p-value
		<1924	1924-1930	1931-1941	1942-1947	1948-1953	1954-1959
	N=6495	N=1,244	N=1,573	N=2,504	N=511	N=440	N=223
Cumulative Trauma ¹
0	1,229 (18.8%)	290 (22.5%)	295 (19.4%)	444 (18.0%)	89 (16.5%)	69 (15.9%)	42 (18.0%)	<0.001
1-2	3,086 (46.9%)	608 (49.3%)	758 (48.4%)	1,200 (47.2%)	232 (44.4%)	181 (41.1%)	107 (47.8%)
3-4	1,646 (25.1%)	291 (23.9%)	409 (25.1%)	660 (26.7%)	123 (24.6%)	117 (26.7%)	46 (17.8%)
5+	534 (9.2%)	55 (4.3%)	111 (7.1%)	200 (8.1%)	67 (14.5%)	73 (16.3%)	28 (16.4%)
Early Life Trauma ²
0	4,090 (60.7%)	927 (73.8%)	1,059 (67.5%)	1,540 (59.9%)	265 (49.1%)	193 (46.4%)	106 (43.2%)	<0.001
1	1,681 (26.5%)	263 (21.9%)	385 (24.5%)	682 (28.0%)	156 (31.1%)	131 (27.4%)	64 (28.5%)
2	528 (9.2%)	41 (3.2%)	102 (6.5%)	213 (9.2%)	66 (14.8%)	73 (16.7%)	33 (15.7%)
3+	195 (3.6%)	13 (1.1%)	27 (1.6%)	68 (2.9%)	24 (5.1%)	43 (9.4%)	20 (12.6%)
Lifetime trauma
Death of child	1,541 (21.1%)	336 (23.8%)	407 (26.0%)	616 (22.9%)	84 (14.6%)	63 (12.3%)	35 (10.7%)	<0.001
Natural disaster	1,403 (22.3%)	255 (22.7%)	331 (21.0%)	530 (21.0%)	127 (25.7%)	111 (25.8%)	49 (19.1%)	0.18
Weapon in combat	668 (11.0%)	178 (14.6%)	216 (13.3%)	168 (7.0%)	49 (11.0%)	52 (15.0%)	5 (3.9%)	<0.001
Partner with drug addiction	1,289 (20.2%)	162 (13.1%)	292 (18.4%)	556 (22.4%)	118 (23.4%)	102 (21.3%)	59 (30.5%)	<0.001
Victim of physical attack	486 (8.4%)	49 (4.0%)	93 (6.3%)	176 (7.2%)	57 (12.3%)	71 (15.7%)	40 (18.3%)	<0.001
Prior life-threatening illness	2,634 (42.4%)	433 (37.3%)	630 (39.7%)	1,050 (42.9%)	232 (48.7%)	205 (49.2%)	84 (41.6%)	0.001
Spouse/child life-threatening illness	2,283 (34.7%)	459 (38.0%)	622 (39.4%)	883 (36.2%)	149 (27.5%)	124 (28.9%)	46 (20.3%)	<0.001
Early life trauma ²
Repeat a school year	1,166 (19.0%)	147 (11.9%)	240 (15.6%)	486 (19.8%)	114 (24.9%)	129 (29.3%)	50 (21.1%)	<0.001
Trouble with police	269 (6.3%)	10 (1.3%)	39 (2.8%)	97 (5.3%)	36 (10.5%)	48 (11.3%)	39 (22.8%)	<0.001
Alcohol or drugs in family	956 (16.2%)	86 (6.9%)	171 (10.9%)	396 (16.5%)	118 (24.1%)	120 (27.3%)	65 (33.1%)	<0.001
Physically abused by parents	465 (8.2%)	43 (3.8%)	80 (5.0%)	182 (8.0%)	57 (12.5%)	81 (17.1%)	22 (13.2%)	<0.001

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Abbreviations: SD – standard deviation; HS – High School; AHEAD - Asset and Health Dynamics among the Oldest Old; CODA – Children of the Depression Age, HRS – Health and Retirement Study; EBB – Early Baby Boomers; MBB – Mid-to-Late Baby Boomers; P-values were determined using Rao-Scott Chi-Square tests or t-tests; ¹cumulative trauma is defined using an 11-item scale (Krause et al. 2004); ²Early life trauma includes 4 items (yes/no) asking respondents about the following experiences before 18 years of age: abuse from parents, trouble with the police, repeating a year of school, and parental drug or alcohol use causing problems for the family.

Associations between traumatic events and end-of-life physical, mental and social well being

Individuals experiencing cumulative lifetime trauma had higher adjusted probabilities of end-of-life moderate-to-severe pain (0 events: 46%; 1-2 events: 50%; 3-4 events: 57%; 5+ events: 60%), fatigue (0 events: 58%; 1-2 events: 60%; 3-4 events: 66%; 5+ events: 69%), dyspnea (0 events: 46%; 1-2 events: 51%; 3-4 events: 56%; 5+ events: 58%), depressive symptoms (0 events: 24%; 1-2 events: 33%; 3-4 events: 37%; 5+ events: 40%), poor life satisfaction (0 events: 73%; 1-2 events: 63%; 3-4 events: 58%; 5+ events: 54%), and loneliness (0 events: 12%; 1-2 events: 17%; 3-4 events: 19%; 5+ events: 22%) (Figure 2; joint Wald test p-values for each symptom were all < 0.001). Traumatic events in early life were associated with higher end-of-life moderate-to-severe pain (0 events: 50%; 1 event: 54%; 2+ events: 59%, p=0.009), depression (0 events: 31%, 1 event: 36%, 2+ events: 39%, p=0.003) and loneliness (0 events: 16%, 1 event: 16%, 2+ events: 25%, p<0.001) (Figure 3). Unadjusted estimates are provided in Supplementary Table 2 and odds ratios and test statistics are provided in Supplementary Tables 3 and 4.

Figure 2. — Adjusted probabilities were derived from multivariate logistic regression models adjusting for age, gender, race and ethnicity, and childhood socioeconomic status. Asterisks on the x-axis represent p-values <0.05 and error bars represent 95% confidence intervals. Cumulative trauma is derived from an 11-item scale (Krause, et al., 2004). Exit interviews asked of proxies were used to assess decedent experiences of moderate-to-severe pain (two part question asking if decedents experienced pain and if it was typically “mild, moderate, or severe”), dyspnea (described as “difficulty breathing”), or fatigue (described as “severe fatigue or exhaustion”) in the last year of life. Mental health and social outcomes were self-reported by respondents within 4 years prior to death, including: depressive symptoms (8-item CES-D scale; ≥3 points on 0-8 scale), life satisfaction (5-items; Range: 5-35 points; 20+ points corresponding to high life satisfaction), loneliness (UCLA 3-item questionnaire; ≥7 points on 3–9 scale), and social isolation (0-6 point scale measuring household contacts, social network interaction, and community engagement, with 0-2 points corresponding to social isolation).

Figure 3. — Adjusted probabilities were derived from multivariate logistic regression models adjusting for age, gender, race and ethnicity, and childhood socioeconomic status. Asterisks represent p-values <0.05 and error bars represent 95% confidence intervals. Early life trauma includes 4 items (yes/no) asking respondents about the following experiences before 18 years of age: abuse from parents, trouble with the police, repeating a year of school, and parental drug or alcohol use causing problems for the family. Exit interviews asked of proxies used to assess decedent experiences of moderate-to-severe pain (two part question asking if decedents experienced pain and if it was typically “mild, moderate, or severe”), dyspnea (described as “difficulty breathing”), or fatigue (described as “severe fatigue or exhaustion”). Mental health and social outcomes were self-reported by respondents within 4 years prior to death, including: depressive symptoms (8-item CES-D scale; ≥3 points on 0-8 scale), life satisfaction (5-items; Range: 5-35 points; 20+ points corresponding to high life satisfaction), loneliness (UCLA 3-item questionnaire; ≥7 points on 3–9 scale), and social isolation (0-6 point scale measuring household contacts, social network interaction, and community engagement, with 0-2 points corresponding to social isolation)

The adjusted associations between individual traumatic events and end-of-life outcomes are presented in Supplementary Table 5. Being a victim of a physical attack and experiencing physical abuse from parents was strongly associated with moderate-to-severe pain, late-life depression, and loneliness. Traumatic events related to family (death of a child, alcohol or drug use by family members, and physical abuse from family) were associated with depression and loneliness.

DISCUSSION

In a nationally-representative sample of older adults in the last four years of life, we found that traumatic events were highly prevalent; nearly 1 in 3 older adults experienced at least 3 cumulative traumatic events and 2 in 5 an early life trauma before the age of 18 years old. The high overall prevalence of trauma cut across gender and birth cohort, although there were notable differences in types of traumatic events. Cumulative traumatic events experienced across the life course were associated with an increased burden of end-of-life physical and psychosocial needs, including moderate-to-severe pain, difficulty breathing, fatigue, depressive symptoms, poor life satisfaction, and frequent feelings of loneliness. Early life trauma, in particular, was strongly associated with pain, loneliness, and depressive symptoms at the end of life. Findings highlight the need for clinicians caring for seriously ill older adults to ensure interdisciplinary care for trauma symptoms and potentially adopting a trauma-informed approach to end-of-life care.

Our findings are broadly relevant to clinicians; everyone will die, and most of us at older ages. Even with a brief 11-item scale, we found that 4 in 5 older adults experienced at least one traumatic event and 1 in 3 experiencing 3 or more events at any point in their lifetime, with comparable prevalence by age groups, gender, race and ethnicity, and socioeconomic status. The results of our study align with others that have also leveraged HRS data to examine the health consequences of life course trauma. For example, Ahn et al. (2024) found that among the entire HRS sample, childhood and adulthood adversities were associated with greater depression, anxiety and cognitive impairment in later life.³³ In a smaller HRS sample, Palgi et al. (2011) found that experiencing potential lifetime traumatic events were associated with greater self-reported loneliness in the second half of life.³⁴

Our estimates are similar to those reported by the National Comorbidity Study, which previously found that more than half of American adults between the ages of 18-55 reported experiencing at least one traumatic event in early life, and data from the Nurses’ Health Study demonstrating that approximately 80% of middle-aged and older nurses experienced at least one traumatic event.^35,36 Our results are also consistent with prior studies among younger adults, veterans, and the prison population.^37-39

Despite similarities in overall prevalence, results indicate gender and birth cohort differences in the types of traumatic events reported. Men were more likely to report traumatic military experiences and for women, the death of a child. This finding is likely related to period and cohort effects. For example, men in our sample lived through multiple wars, including World War II, the Korean War, and Vietnam War; it was only mid-late Baby Boomers who had lower levels of military exposure. Similarly, childhood mortality remained high through the early 20th century. For example, in 1950 infant mortality rate was 51.3 infant deaths per 1000 births compared to 7 per 1000 today.⁴⁰ Notably, early life trauma was more common among later generations (born after 1942), including the need to repeat school years, trouble with the police, alcohol or drugs impacting family life, and experiencing physical abuse from parents. Gender and cohort differences observed in this study are therefore closely tied to distinct social events and norms that unfolded in the United States, which will continue to evolve with successive birth cohorts.

To our knowledge, this study is one of the first to demonstrate that, among those at the end of life, the health effects of cumulative trauma may extend to a higher burden of physical, psychological, and social distress. Cumulative trauma was associated with higher rates of moderate-to-severe pain, dyspnea, fatigue, depressive symptoms, frequent feelings of loneliness, and lower life satisfaction. Early life trauma (particularly physical abuse from parents) was strongly related to end-of-life pain, loneliness and depressive symptoms. For physical symptoms, we hypothesize that trauma may impact psychological, social, and spiritual aspects of end-of-life symptoms (drawing on the hospice concept of “total pain”) and disrupt coping skills. Greater symptom burden may reflect the accumulation of lifelong impacts of trauma on physical functioning, chronic disease risk, immune aging, and mental health outcomes. ^41-44

Lifetime trauma was significantly associated with mental and social well-being, including loneliness, depression, and poor life satisfaction. Firing a weapon (or being fired upon), being a victim of a physical attack or assault, or experiencing physical abuse from parents were strong predictors of mental and social distress, perhaps reflecting ties to post-traumatic stress disorder (PTSD) and moral injury. Serious illness and approaching the last years of life may further force uncomfortable life review which may lead to regret and poor life satisfaction.⁴⁵ Taken together, trauma represents a common factor that is not specific to any one disease which may play a role in the complex interplay between physical symptoms and psychosocial well-being at the end of life.

Our findings suggest that clinicians should adopt a trauma-informed approach to the care of individuals with serious illness and approaching the last months or years of life. This approach assumes prior experiences of trauma and potential contributions to current physical and mental health symptoms. Trauma-informed care uses six key principles to guide care delivery: (1) creating psychological safety; (2) fostering trust and transparency; (3) promoting peer support and mutual self-help; (4) care collaboration and mutuality; (5) patient voice and choice; (6) and tailoring care to be culturally and historically responsive (including by gender and birth cohort membership).^17,46 We do not suggest undertaking a detailed trauma history on all patients, as this could potentially be retraumatizing or unwelcome. However, depending on the available resources, psychosocial expertise, and patient populations, our study results may prompt interdisciplinary clinical teams to actively screen and explore prior traumatic experiences in a structured format (online resources are available at, for example, Center to Advance Palliative Care).⁴⁷

Evidence for the effectiveness of trauma-informed care to reduce patient symptoms is currently limited to psychiatric and geriatric settings. For example, these approaches have reduced use of restraints, sedating medications, and increased patient satisfaction with care.^48-51 Although these interventions have not been applied to patients with life-limiting illness, the end of life may be a critical time to re-engage with traumas to find meaning and coherence (e.g. later-adulthood trauma reengagement).³⁷ Applying existing evidence-based treatments for post-traumatic stress (e.g., eye movement desensitization and reprocessing, cognitive processing therapy, prolonged exposure)⁵² may be limited by an individual’s life expectancy, symptom burden, and competing health and social priorities. Future research is therefore needed on how to develop new interventions for and tailor existing trauma-informed care interventions to patients with serious illness and outcomes relevant to the end of life.

We note several limitations. First, we cannot rule out the possibility of recall bias given the retrospective assessment of our primary exposure and the long lag time that may have ensued. Prior research has also demonstrated that recall bias may be strongest among those with PTSD symptoms and/or cognitive impairment and may also differ by gender.^53,54 However, previous research suggests individuals recall the timing of past traumatic events with reasonable accuracy.^55,56 Nonetheless, a prospective study following individuals from birth to death is likely infeasible as we would need to wait another 80 years for those data for a study that begins today. Second, the pathway linking traumatic events to late life health is lengthy and complex. We acknowledge there are several intermediate and intervening factors on the causal pathway that pose both measurement and analytic challenges. We chose to employ parsimonious models that controlled for true confounders and not mediators in order to avoid over-adjustment, which can lead to incorrect effect estimates.³² Third, we treated each traumatic event with equal weight and are unable to fully quantify the magnitude or severity of these adverse events both within and across respondents. We also acknowledge that certain types of trauma were not included (i.e., sexual trauma, racial trauma) in our summary measures. Future work should pinpoint the type, duration, timing, and severity of the event experienced. Lastly, like with any cohort study that focuses on older adult health, we cannot the rule out selection bias. However, if sicker individuals are more likely to die earlier in the life course, our effect estimates would therefore reflect a conservative estimate of the true association.

In conclusion, older adults in the last years of life report a high prevalence of traumatic events which are associated with a greater burden of physical symptoms and psychosocial needs at the end of life. Clinicians should consider a trauma-informed approach to overall end-of-life care and management of physical and psychosocial needs.

Supplementary Material

Supinfo

Supplementary Figure 1. Sample flow diagram in Health and Retirement Study

Supplementary Table 1. Traumatic Life Event Questions from the Health and Retirement Study LeaveBehind Questionnaire

Supplementary Figure 2. Prevalence of Cumulative Trauma Across Age, Gender, Race and Ethnicity, and Wealth Quartile

Supplementary Figure 3. Age-adjusted Prevalence of (A) Cumulative Trauma and (B) Early Life Trauma, Stratified by Gender

Supplementary Table 2. Unadjusted and Adjusted Associations of Trauma with end-of-life physical, mental, and social well-being

Supplementary Table 3. Adjusted Probabilities and Odds Ratios Showing the Adjusted Association of Collective Trauma with End-of-Life Symptoms

Supplementary Table 4. Adjusted Probabilities and Odds Ratios Showing the Adjusted Association of Early Life Trauma with End-of-Life Symptoms

Supplementary Table 5. Adjusted Association of Individual Traumatic Events with end-of-life physical, mental, and social well-being

NIHMS2024719-supplement-Supinfo.pdf^{(640KB, pdf)}

Key points:

In a national sample, one third of adults nearing the end of life reported three or more potentially traumatic events over their lifetime.
After statistical adjustment, cumulative lifetime trauma was significantly associated with greater moderate-to-severe pain, fatigue, dyspnea, depression, and loneliness, and lower life satisfaction at the end of life.

Why does this paper matter?

Clinicians should consider a trauma-informed approach to the care of adults approaching end of life and recognize the potential role of past trauma when addressing end-of-life physical symptoms and psychosocial needs.

ACKNOWLEDGEMENTS

Funding: This project was supported by grants from the National Institute on Aging (K23AG065438 to AK; P30AG044281 to AK, AKS, IC; K24AG062785 to AKS; R00AG066846 to KD; R00AG062749 to GN) and the Department of Veterans Affairs (IK6 CX002386 to AB).

Sponsor’s Role:

The sponsor had no role in the design, methods, data collection, analysis, or preparation of the paper.

Footnotes

Conflicts of Interest: AK and CP report personal consulting fees from Papa Health outside of the submitted research.

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