Posttraumatic stress disorder in older adults: A Global Collaboration on Setting the Future Research Agenda

Summary

Despite the significant public health and social care burden associated with posttraumatic stress disorder (PTSD) in late life, systematic research in this field remains limited. This paper presents the positions of the ON TRAumatiC stress and ageing: a global networK (ON TRACK) task force, part of the Global Collaboration on Traumatic Stress (GCTS). We synthesize evidence-based knowledge of PTSD in late life across four key clinical domains: ageing mechanisms, assessment, mental health treatment, and care for older trauma survivors. Reviewing 97 papers, we integrate the available evidence and identify key research priorities based on the consensus of ON TRACK members. Our position paper highlights the urgent need for high-quality research on older trauma survivors across all four domains. Future studies should focus on individuals aged 60 and older, particularly women, those with multiple comorbidities, including neurocognitive disorders, and underrepresented populations from non-Western countries.

Introduction

Due to increasing longevity, it is estimated that over 22% of the global population will be older than the age of 60 by 2050 (World Health Organization, WHO, 2017)¹. As a result, the number of older people living with mental illness is also projected to increase. Despite the negative impact that mental illness has on older adults’ quality of life, physical health and daily functioning, late-life psychiatric disorders remain under-identified and under-treated. Improving older adults’ mental health is a public health and social care priority in several countries as highlighted in the WHO’s comprehensive mental health action plan (WHO, 2021).

Many older people are affected by exposure to potentially traumatic experiences, which negatively impacts their mental health. A significant majority (70.4%–88.7%) of the general population will experience at least one potentially traumatic event (e.g., traumatic loss of a loved one, accident, sexual assault) in their lifetime². Traumatic exposure during early childhood, in particular, has been shown to increase the risk of developing both mental and physical illnesses in mid-life and late-life, with post-traumatic stress disorder (PTSD) being one of the most well-known outcomes³. Given the widespread occurrence of traumatic events globally, addressing PTSD as a critical public health concern is essential.

Trauma does not only contribute to the development of PTSD but also increases the risk of other mental health disorders, including depression, alcohol abuse, and personality disorders⁴. Trauma and PTSD are associated with a higher likelihood of developing physical health conditions throughout one’s lifespan, such as cardiovascular disease and diabetes^{5, 6}, and increase risk of dementia onset⁷. Understanding the mechanisms that underlie the relationship between PTSD and aging is critical for informing preventive strategies across multiple sectors, including home care, social care, aging policy, brain health equity, and mental health services.

Accurate diagnosis for PTSD continues to remain a clinical challenge, especially in older adults. This is partly due to the complex nature of PTSD and the physiological and psychological changes associated with aging^{8, 9}. Current evidence suggests that PTSD tends to remain relatively persistent over time¹⁰. However, an intermittent course with relapses including late-life exacerbation of symptoms, is more common in older adults¹¹. These relapses can be triggered by experiences of loss (i.e., retirement, bereavement) or decrements in daily functioning. The phenomenon of ‘Delayed presentation’ of PTSD describes individuals who initially manage to cope with traumatic events but develop PTSD symptoms many years or even decades later¹⁰.

Global lifetime prevalence of PTSD varies from to 3.9%¹² - 7.4%², with lower rates in older adults (≥60 years) compared to younger age groups^{13, 14}. These age-related differences may be attributable to evolving definitions and recognition of PTSD over time¹⁵. Furthermore, many individuals exhibit sub-threshold symptoms, which do not meet the full diagnostic criteria for PTSD. Among these individuals, avoidance symptoms are often absent, while cognitive difficulties are more prevalent¹⁶. Consequently, PTSD in older adults is frequently underdiagnosed¹⁷, highlighting the critical importance of accurate clinical assessment in this population to ensure timely access to mental health care.

Current treatments for PTSD in late life are based primarily on approaches and interventions for younger adults. Even when diagnostic criteria for PTSD are not fully met, trauma-focused therapy, such as prolonged exposure (PE) and eye movement desensitization and reprocessing (EMDR), have shown to be feasible, and acceptable¹⁸. These protocols, originally developed for younger adults, are often adapted to meet the needs of older people¹⁹. For instance, recent case reports suggest that EMDR may be feasible for individuals with dementia²⁰. However, clinical effectiveness studies of both pharmacological and non-pharmacological treatments often exclude older adults, with many failing to report specific outcomes for this age group, leading to a significant gap in the evidence base for treating PTSD in late life.

PTSD symptoms can also significantly impact older adults’ access to care services, both in community and long-term care settings²¹. Many aspects of care delivery (i.e. locked wards, delivery of personal care, limited privacy), can serve as trauma reminders, triggering stress reactions for the person with PTSD and care staff. Cognitive impairment and dementia can further increase sensitivity and reactivity to trauma²², reducing peoples’ capacity to avoid triggers²³ and self-regulate emotions and distress. Notably, trauma survivors with dementia are more likely to exhibit neuropsychiatric symptoms, such as aggression, agitation, than those without a trauma history²⁴.

Improving outcomes for older adults with a history of trauma requires creating care environments that prioritize safety and accessibility. This is often problematic as staff in nursing home care settings often receive minimal training on mental health, including PTSD needs²⁵. Trauma-informed care (TIC) offers a promising framework by recognizing that both care recipients and providers may have experienced trauma. TIC emphasizes a system-wide understanding of trauma and the implementation of care practices that minimize the risk of re-triggering trauma-related symptoms²⁶. In mental health and long-term care settings, TIC can reduce traumatic stress symptoms, and improve quality of life and care quality for the care recipient. TIC practices can also reduce service costs, staff burnout, and workforce turnover²⁷. However, the utility of TIC in nursing home settings has not yet been systematically investigated. To improve the prognosis for older individuals affected by trauma, a better understanding of the ageing mechanisms, early recognition of PTSD, and the provision of effective, personalized care are essential to promoting healthy aging.

The aim of this position paper is to provide a comprehensive review of the current evidence base on PTSD and ageing, with the goal of strengthen and accelerating global research in this field. Specifically, we aim to: i) explore and identify ageing mechanisms across the life span, ii) evaluate current assessment and diagnosis instruments, iii) investigate the clinical effectiveness of treatments and iv) identify models of care that can improve recognition and future implementation of evidence-based interventions. The Global Collaboration on Traumatic Stress (GCTS) commissioned a task force of experts on traumatic stress and aging, including individuals with lived experience, to address this critical issue. The ON TRAumatiC stress and aging global networK (ON TRACK) members developed positions grounded in current evidence and systematic reviews to inform clinical practice, research, and policies. A research agenda is formulated across four key domains, integrating available evidence and expert consensus from ON TRACK members.

Search strategy and selection criteria

For the four domains we performed separate systematic reviews searches in the following databases:

1. Ageing mechanisms; We searched Embase, Medline and PsycInfo up until 8 May 2023 to review evidence on neurobiological and psychosocial mechanisms linking trauma and ageing across the life-course using a combination of standardized search terms and keywords for PTSD and ageing (see Appendix 1 for details of the search terms).

2. Assessment; A review was done using: Medline, Embase, PsycINFO up until 25 November 2022 for evidence base on: a) diagnostic accuracy with respect to sensitivity and specificity on assessment of trauma and PTSD in late life using the following search terms: assessment, diagnosis and relevant terms (see Appendix 2 for details of the search terms).

3. Treatment; A review was done with a comprehensive search up until 25 December 2022: MEDLINE, EMBASE, PsychINFO, CINAHL, PILOTS, PTSDPubs, CENTRAL (Cochrane Central Register of Controlled Trials). We also searched clinicaltrials.gov, and pre-print services (bioRxiv, medRxiv, and PsyArXiv) using terms related to PTSD and trauma symptoms in older people (See Appendix 3 for details of the search terms).

4. Care; A review was done using Medline, Embase, PsycINFO up until 13th November 2023. We searched for literature on care for trauma survivors using the following search terms: (older adults OR elderly) AND (trauma informed care OR TIC OR traumatic stress care OR trauma sensitive care) AND a standardized list of PTSD/ trauma (see Appendix 4 for details of the search terms).

Inclusion criteria:

1. Population: age ≥ 60 years except for Ageing Mechanisms where no age restrictions were applied to capture a life-course perspective,

2. A diagnosis of PTSD according to the Diagnostic and Statistical Manual of Mental Disorders (DSM), International Classification of Diseases (ICD), or those with clinically relevant symptoms of PTSD,

3. Articles written in English,

4. Ageing mechanisms domain: human studies,

5. Assessment domain: Studies restricted to participants confirmed to either have (or to have had) the target condition (to estimate sensitivity) or confirmed not to have (or have had) the target condition (to estimate specificity). Single‐group studies (which recruited participants before disease status has been ascertained), multi‐group studies (where people with and without the target condition are recruited separately (often referred to as two‐gate or diagnostic case‐control studies), and studies based on patients.

6. Treatment domain: Randomized Controlled Trials (RCT) (all types; pharmacological and non-pharmacological treatments comparing pharmacological and non-pharmacological interventions with treatment as usual, 2) older people in any setting (community, inpatient, or long-term care).

7. Care domain: Studies of any design describing the implementation of trauma-informed care models in care home settings (e.g., long-term care, inpatient geriatric care services, home-based elder care). Because trauma-informed care lacks an agreed operational definition, any interventions or systems of care specifically described as “trauma-informed” were included.

To ensure quality of included papers we used the following quality rating for the specific domains:

1. Ageing mechanisms: Due to the large variation in methods no uniform criteria were available for this domain.

2. Assessment: Screening and assessment: QUADAS‐2 (Quality Assessment tool for Diagnostic Accuracy Studies²⁸).

3. Treatment: the Cochrane Risk of Bias tool for randomized controlled trials (RoB2)²⁹.

4. Care: Due to the limited evidence on care for older people who have experienced traumatic stress, identified studies were reviewed narratively and risk of bias was not conducted.

Ageing mechanisms

One hundred and forty-six articles were identified of which 24 were included following full-text review, supplemented by an additional 40 studies identified based on cross-referencing (Mage = 54.73) (See Table 1). Studies were divided into four categories: a) physiological and metabolic (n=18), b) molecular and cellular (n=21), c) brain structure and functioning (n=12), and d) psychosocial (n=13) mechanisms.

Table 1.

Summary of validated PTSD instruments in older adults (Mean_age ≥60 years)

Physiological and metabolic mechanisms
Study	Design	Subjects (N, population type, ethnicity, sex ratio)	Range age	Main finding
Bourassa et al. (2023)	Longitudinal	N=955, Dunedin cohort (New Zealand), White (93%), Male: 51%	26–45	A clear relationship between stress level and biological aging was found. People with trauma exposure who did not develop PTSD were aging more slowly than those with PTSD, but faster than those with no trauma or PTSD (0.96 biological years per chronological year, 95% CI = 0.94–0.98 years).
Green et al. (2016)	Cross-sectional	N=204,Vietnam Era veterans Caucasian (62.2%), Male: 100%	55–89	There was an interaction between MetS and PTSD on delayed verbal memory, suggesting that the negative impact of MetS on verbal memory was only significant for veterans not classified as having PTSD.
Levert-Levitt et al. (2022)	Cross-sectional	N=189,Veterans (Israel),Male: 100%	56–84	Discovered a microbiome signature of PTSD (decreased levels of the bacteria sp_HMT_914, 332 and 871 and Noxia) correlated with PTSD severity. Oral microbiome metabolic activity showed reductions in transaldo- lase, an enzyme controlling a major cellular energy pathway, that potentially accelerates aging in correlation with excessive arousal and reactivity.
Song et al. (2015)	Cross-sectional	N=86, Outpatients, Asian (100%), Female: 58.14%	36–74	The MS group showed a significant reduction in mean cortical thickness and volume in both hemispheres compared with controls.
Wilson et al. (2005)	Longitudinal	N=2549, Framingham Offspring Study, White (100%), Female: 51.78%	22–81	Metabolic syndrome is common and is associated with an increased risk for CVD and T2DM in both sexes.
Wolf et al. (2016)	Longitudinal	T1: N=1355, T2: N=971, War veterans, White (64.8%), Female: 51.7%	22–69	The prevalence of MetS among veterans with PTSD was just under 40% at both time points and was significantly greater than that for veterans without PTSD. Logistic regression results suggested that for every 10 PTSD symptoms endorsed at time 1, the odds of a subsequent MetS diagnosis increased by 56%
Molecular and cellular
Avetyan et al (2019)	Cross- sectional	N=90, Combat veterans, Asian (100%), Male:100%	34–63	Comparison of LTL in diseased and healthy subjects showed that PTSD patients had shorter average LTL than controls. rs2736100 of TERT gene was significantly associated with PTSD and the minor allele of this polymorphism may be considered as a risk factor for PTSD in the Armenian population
Boks et al (2015)	Longitudinal	N=96, Military personnel , Dutch (100%), Male: 100%	n.a	Trauma significantly accelerated epigenetic ageing (B = 1.97, p = 0.032) and similar to the findings in telomeres, development of PTSD symptoms was inversely associated with epigenetic ageing (B = −0.10, p = 0.044)
Bourassa et al (2024)	Cross-sectional	N=2309, War veterans, Non-hispanic black (48%), Male: 78.7%	n.a	Veterans with current PTSD were aging faster than those who did not have current PTSD, β=0.18, 95% CI [0.11, 0.27], p < .001. This effect represented an additional 0.4 months of biological aging each year. Veterans were also aging faster if they reported more PTSD symptoms, β=0.13, 95% CI [0.09, 0.16], p< 0.001
Burgin et al (2022)	Cross-sectional	N=130, Previous youth residential care placement, Male: 69.2%	16–39	A higher burden of CAs, PTEs, Criterion A trauma, and PTSD was associated with longer TL. PTEs, Criterion A trauma, and PTSD were associated with lower HCC, however no significant asso ciations between CAs and HCC were found
Carvalho et al (2022)	Longitudinal	N=124, War captivity (Brazil), Female: 100%	18–45	LTL was associated with re-experiencing symptoms (B = −0.16; confidence interval (CI) 95% = −0.027—−0.005; Bonferroni-adjusted p-value = 0.02), but no association was observed between other PTSD symptoms and LTL. In the longitudinal analysis, telomere shortening was no longer observed in patients with PTSD and PTSD remitters.
Ladwig et al (2013)	Cross-sectional	N=3000, population-based KORA, Male: 49.5%	25–74	The multiple model revealed a significant association between partial PTSD and TL (beta=20.051,p=0.009) as well as between full PTSD and shorter TL(beta=20.103,p=0.014) indicating shorter TL on average for partial and full PTSD
Malan et al (2011)	Longitudinal	N=64, Raped survivors Mixed ancestry, (80%), Female: 100%	14–43	No significant associations were observed between relative LTL and resilience or the development of MDD at either baseline or after 3 months in this cohort. However, a marginally significant association was evident between relative LTL and PTSD status
Morrison et al (2019)	Longitudinal	N=179, War veterans, White (74.9%) , Male: 88.3%	n.a	PTSD symptom severity at T1 predicted decreasing (i.e., worsening) CD4/CD8 T-cell ratios at T2. The ratio of CD4 to CD8 T-cells has been consistently used as a marker of dysregulated immune function and immunosenescence
O’Donovan et al (2011)	Cross-sectional	N=90, Recruited trough flyer distribution White (60%) Female: 56%	21–49	Participants with PTSD had shorter age-adjusted LTL than controls: only participants with PTSD and exposure to multiple categories of childhood trauma had significantly shorter LTL than controls
Roberts et al (2017)	Longitudinal	N=116, Rape, interpersonal violence, sudden death of beloved, White (97.2%), Female: 100%	32–52	Relative to not having PTSD, women with a PTSD diagnosis had shorter log-transformed TL (β=−0.112, 95% confidence interval=−0.196, −0.028)
Shalev et al (2014)	Longitudinal	N=1037, Dunedin cohort (New Zealand), White, Male: 52%	11–38	While LTL erosion was accelerated among men who experienced depression and GAD, the association for PTSD among men was in the same direction but did not reach significance (β = − 0.065, 95% CI: −0.147, 0.017; P = 0.120). No significant associations were found among women in any analysis, highlighting potential sex differences in internalizing-related telomere biology.
Solomon et al (2017)	Longitudinal	N=99, War captivity, Male: 100%	61–77	The patients who had a trauma history had shorter telomeres than controls [F(1,171) = 6.13, p = 0.01. Cohen’s d = .5 indicating intermediate effect)] However, contrary to the hypothesis, findings demonstrated that PTSD trajectories were not implicated in telomere length.
Verhoeven et al (2018)	Cross-sectional	N=160	n.a
Wolf et al (2019)	Longitudinal	N=179, War veterans, White (75.4%), Male: 88.3%	19–65	PTSD avoidance and numbing symptoms (p = .02) at Time 1 were associated with an increasing pace of the epigenetic clock over time, per the Horvath index of cellular aging
Wolf et al (2016)	Cross-sectional	N=281, Veterans, White (70.5%), Male: 87.9%	19–58	Results provide novel support for PTSD-related accelerated aging in DNAm: DNAm age was strongly related to chronological age (rs ~.88). Lifetime PTSD severity was associated with Hannum DNAm age estimates residualized for chronological age (β = .13, p= .032).
Wolf et al (2018)	Longitudinal	N=339, Veterans and partners, White (100%), Male: 87%	23–72	PTSD hyperarousal symptoms were associated with accelerated DNAm age (β = .20, p = .009) but trauma exposure and total PTSD severity were not
Wolf et al (2024)	Longitudinal	N=214, Veterans, White (75.2%), Male: 84.6	28–78	Results suggest that advanced GrimAge is predictive of subsequent increases in neuropathology and inflammatory biomarkers as well as worse cognitive function, highlighting the clinical significance of this biomarker with respect to cognitive aging and brain health over time. Advanced GrimAge mediated the association between psychiatric comorbidity and future neuropathology
Brain structure and functioning
Franz et al (2018)	Longitudinal	N=1237, Vietnam-era, veterans, White (89%), Male: 100%	51–59	Combat exposure was significantly associated with PTSS at age 38, F(4, 464) = 11.09, b = .01, standard error (SE) = .002, p < .012. PTSS, but not combat exposure, significantly predicted later hippocampal volume and hippocampal occupancy: men with higher levels of PTSS at age 38 had smaller hippocampal and greater hippocampal atrophy approximately 2 decades later. PTSS at age 38 significantly predicted worse outcomes on most measures at age 62 in adjusted models
Franz et al. (2020)	Longitudinal	N=370, War veterans, (Israel), Male: 100%	T1: 32–44 T2: 56–67	Higher PTS symptoms averaged over time and symptoms at time 1 were both associated with lower hippocampal, amygdala, rostral middle frontal gyrus (MFG), and medial orbitofrontal cortex (OFC) volumes, and a lower HOC ratio at time 2. Increased PTS symptomatology from time 1 to time 2 was associated with smaller hippocampal volume, Even at sub-diagnostic threshold levels, PTS symptoms were present decades after trauma exposure in parallel with highly correlated structural deficits in brain regions regulating stress responsivity and adaptation.
Wang et al (2016)	Longitudinal	N=81, Taiwan National Health Insurance (NHI) database, Asian (100%), Female: 76.6%	Over 45	There was a dose-dependent relationship between PTSD severity indicated by the frequency of psychiatric clinics visiting of PTSD (times per year) and the risk of subsequent dementia (o5: HR: 2.81, 95% CI: 1.50–5.29; 5–10: 6.90, 95% CI: 3.09–15.40;410: HR: 18.13, 95% CI: 9.13–36.00).
Wolf et al (2016)	Cross-sectional	N=346, Veterans, White (71.4%), Female: 89.3%	22–69	Path models showed that PTSD predicted MetS (β = .19, p < .001), which, in turn, was associated with reduced cortical thickness (βs from −.29 to – .43, all p <.001)
Yaffe et al (2010)	Longitudinal	N=181093, Veterans, Male: 96.5%	55–100	Veterans with PTSD had a 7-year cumulative incident dementia rate of 10.6% whereas those without had a rate of 6.6% (P<.001).
Romaniuk et al (2022)	Cross-sectional	N=68, Veterans, Caucasian (75%) Male: 100%	64–88	Findings from this study reinforce reports of white matter alterations, as indicated by reduced fractional anisotropy values, in relation to PTSD symptom severity, as well as patterns of reduced volume in the prefrontal cortex
Eising et al (2022)	Longitudinal	N=110, Longitudinal Healthy Aging Brain Database, Female: 50%	Over 64	The reporting of PTSD symptoms relative to no symptoms was associated with lower within-DMN connectivity, while on a trend level trauma-exposed individuals showed higher within-SN connectivity compared to non-trauma exposed individuals. Consistent with existing models of healthy aging, between-DMN-SN functional connectivity showed an increase across time in older age.
Psychosocial
Escarfulleri et al (2021)	Longitudinal	T1: N=860, T2: N=503, Veterans, White (83.8%), Male: 91.5%	22–96	PTSD symptoms are associated with worse diet quality and that the consumption of unhealthy food may be driven by efforts to suppress emotion.
Goldstein et al (2016)	Cross-sectional	N=36309, National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), Native american (13%), Female: 27%	n.a	PTSD was significantly associated with a broad range of substance use, mood, anxiety, and personality disorders, and past-month disability.
Muniz Carvahlo et al (2021)	Cross-sectional	N=148164, Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE), European ancestry (100%)	40–69	Findings highlight a bidirectional genetic association between PTSD and CRP, also suggesting a potential role of SES in the interplay between childhood support and inflammatory processes with respect to PTSD risk
Rajai et al (2024)	Cross-sectional	N=280324, Mayo clinic outpatients, White (86.3%), Female: 50.9%	Over 18	Social isolation is associated with accelerating biological aging and all-cause mortality independent of conventional cardiovascular risk factors
Roberts et al (2020)	Longitudinal	N=54687, Nurses’ Health Study II cohort, White (97.2%), Female: 100%	43–64	Women with PTSD symptoms and probable depression, compared with women with no PTSD or depression, had higher rates of death from cardiovascular disease, diabetes and suicide.
Skinner et al (2023)	Cross-sectional	N=3701, Women’s Health Initiative (WHI) cohort, White (70.9%), Female: 100%	50–79	Elevated stress burden is associated with accelerated epigenetic aging in postmenopausal women. Lower social support and/or self-reported race/ethnicity may modify the association of stress with epigenetic age acceleration.

a). Physiological and metabolic mechanisms:

Three longitudinal studies, 3 cross-sectional studies, 8 narrative reviews, and 4 systematic reviews and meta-analyses were identified. PTSD was associated with accelerated physiological and metabolic ageing. In one longitudinal study people with PTSD exhibited the most rapid biological ageing compared to those without PTSD or trauma exposure when using the Pace of Ageing clock³⁰. PTSD was also associated with both metabolic syndrome (MetS) and immune-mediated inflammatory dysregulation^31–34. PTSD patients exhibited higher concentrations of inflammatory markers (e.g., C-reactive protein, interleukin 6, and tumor-necrosis factor α) compared to healthy controls^{32, 35}. One longitudinal study on 1,355 male and female veterans reported higher prevalence of MetS among people with PTSD and showed that MetS increases proportionally with PTSD symptoms³⁶. Two meta-analyses indicated a MetS prevalence of approximately 40% in individuals with PTSD^{37, 38}. Accelerated epigenetic ageing and increased MetS are suspected to link PTSD to neuropathological age-related disease and mortality risk factors^{39, 40} in general, and in trauma and PTSD in particular through changes in immune function and immune-senescence markers, such as T-cell levels.

b). Molecular and cellular mechanisms:

Ten longitudinal studies, 7 cross-sectional, 2 narrative reviews, 1 systematic review, and 1 meta-analysis were identified. The association between PTSD severity and leukocyte telomere length (LTL) is mixed^41–44. In one longitudinal study, PTSD symptomology was associated with LTL increase⁴³, consistent with prior cross-sectional studies^45–47. Stronger associations between PTSD and LTL in men vs women were reported^48–50. Studies linking PTSD with changes in deoxyribonucleic acid (DNA) methylation (DNAm)³⁹ and health outcomes, showed that specific symptom clusters rather than severity were strongly associated with epigenetic age^{51, 52} dependent on epigenetic clocks type^{43, 53–56}.

c). Brain structure and functioning:

Five longitudinal studies, 2 cross-sectional study, 2 narrative reviews, 1 systematic review, and 2 meta-analyses were identified. Several studies showed that people with PTSD have a higher risk of developing dementia, with changes in brain structure such as hippocampal atrophy and changes in cortex volume, hypothesized as one possible underlying mechanism^57–59. Higher levels of PTSD symptoms have been longitudinally linked to smaller hippocampus volumes, greater hippocampal atrophy –linked to Alzheimer’s disease and ageing⁶⁰, lower amygdala, rostral middle frontal gyrus, and medial orbitofrontal cortex volumes, and hippocampal Occupancy Score (HOC) ratio in men⁶¹. Additionally, white matter microstructural changes were reported in a sample of veterans with an average symptom duration of 30.95 years (+15.61). Significant negative correlations were found between PTSD symptom severity and fractional anisotropy values in the left corticospinal tract and left inferior cerebellar peduncle⁶². Finally, PTSD symptoms in the older adult population were longitudinally associated with functional connectivity differences, specifically, lower within-default mode network connectivity⁶³.

d). Psychosocial:

Two longitudinal studies, 4 cross-sectional studies, 2 narrative reviews, 1 systematic review, and 4 meta-analyses were identified. While studies have not directly assessed the role of social support or similar constructs, such as loneliness, in biological aging among individuals with PTSD^64–66, social isolation and loneliness have been prospectively tied to higher all-cause mortality risks in cohort studies⁶⁷. Emerging evidence further links social isolation to markers of biological aging, even after adjusting for cardiovascular risks⁶⁸.

Assessment

We identified 20 studies that investigated a PTSD screening or diagnostic instrument in older adult samples (Mage ≥ 60 years, see Table 2)^69–88. Only two studies (2/20; 10%) were conducted with participants from either the general population or primary care settings. Half of the studies (10/20; 50%) were conducted with military veteran samples. There were only three studies reporting on the diagnostic accuracy of assessment in older adults, independent of the DSM, in the last ten years. Only one study tested a diagnostic instrument based on the DSM-5 (i.e., Clinician Administered PTSD Scale-DSM-5 [CAPS-5]), which was conducted with U.S. military veterans. No PTSD screening or diagnostic instruments have been validated for older adults with cognitive decline, impairment, or dementia. We found no studies using a PTSD diagnostic or screening instrument based on the ICD. Finally, very few studies assessed any PTSD instrument for older adults in non-Western (1 study), and/or non-English speaking (8 studies) samples. The CAPS-5, recognized as the gold standard interview for assessing current and lifetime PTSD, is the only DSM-5-based instrument that has been validated for use in older adults.

Table 2.

Summary of validated instruments in older adults (M_age ≥ 60 years)

Instrument	DSM Version	Sample Population
CAPS-1	DSM-III	Veterans75
CAPS-5	DSM-5	Veterans72
Dutch PTSD Scale	DSM-III	Veterans73
IES	DSM-III	POWs & Veterans70, POWs75 Veterans85
IES-R Greek version	DSM-IV	Cancer patients80
MMPI	DSM-III	POWs, Veterans with PTSD & Psychiatric Veteran Patients76, POWs81
MMPI-2 Pk	DSM-III	POWs & Veterans70
M-PTSD	DSM-III	Veterans69, POWs & Veterans70, POWs, Veterans with PTSD & Psychiatric Veteran Patients76, POWs81
PCL-C	DSM-IV	Medical/Psychiatric hospital patients74, Trauma-exposed (hurricane)84
PCL-M	DSM-IV	Veterans (currently working as peacekeepers)87
PCL-S	DSM-IV	Primary care patients68, Veterans69, Trauma-exposed (earthquake, nuclear power plant incident and Fukushima evacuees)77, Trauma-exposed (hurricane)82
PC-PTSD Korean version	DSM-IV	Veterans78
PTSS Scale	DSM-IV	Primary care patients83
SIPS	DSM-IV	Veterans78
SRIP	DSM-IV	General population86
SQD	DSM-IV	Trauma-exposed (earthquake)71
TSI	DSM-III	Former Swiss placement and institutional children79

Note. The “Instrument” column contains the title of the instrument tested, the “DSM Version” column contains the version of the DSM that the test instrument was based upon, and the “Sample Population” column contains the corresponding studies that tested the instrument; full instrument names and corresponding studies are indexed by citation number in the reference list; DSM = Diagnostic and Statistical Manual of Mental Disorders; CAPS = the Clinician-Administered PTSD Scale; IES = the Impact of Event Scale; MMPI = the Minnesota Multiphasic Personality Inventory; M-PTSD = the Mississippi Scale for Combat-Related Posttraumatic Stress Disorder; PCL = PTSD Checklist; PC-PTSD = the Primary Care PTSD Screen; POW= Prisoners of War; PTSD= Posttraumatic Stress Disorder; PTSS Scale = the Posttraumatic Stress Syndrome Scale; SIPS = the Single-Item Posttraumatic Stress Disorder Screener; SQD = the Screening Questionnaire for Disaster Mental Health; TSI = the Trauma Symptom Inventory.

Treatment

A small evidence base consisting of 10 randomized controlled trials (RCTs) was identified^{19, 89–97}. As seen in Table 3, sample sizes were small and ranged from 10 to 191 participants. Overall, the 10 studies reported feasibility and acceptability data, while only one assessed clinical effectiveness. The majority of trials recruited older people (≥60 years) with a diagnosis of PTSD, with two trials including people with subsyndromal symptoms. In most studies the nature of trauma was specified; this included war-related trauma, interpersonal trauma (e.g., sexual abuse, domestic abuse), trauma associated with a natural disaster, being a Holocaust survivor or a political detainee. Two studies did not provide details of trauma exposure^{91, 94}. All studies except for one⁹⁴ assessed PTSD symptoms; this trial focused on the long-term effects of PTSD on depression severity, and consequently, only depression symptoms were assessed. The most common secondary outcome was depressive symptoms, followed by anxiety, and quality of life. The interventions tested included narrative exposure therapy (4 trials), spiritual focused psychotherapy (1 trial), collaborative care (1 trial), trauma-focused cognitive behavior therapy (CBT) (1 trial), internet delivered CBT (1 trial), life review therapy (1 trial), and physical activity counseling (1 trial).

Table 3.

Summary of Randomized Controlled Trials on Treatment in Older Adults with PTSD (Post Traumatic Stress Disorder)

Study	Sample	Intervention and control groups	Outcomes assessed	Results
Bichescu et al., 2007	Older survivors of political detention and torture with a diagnosis of PTSD87 (n = 18)	Narrative exposure therapy vs psychoeducation	- PTSD symptoms - Depressive symptoms	- PTSD and depressive symptoms improved
Gamito et al., 2010	War veterans with PTSD (n = 10)88	Virtual reality exposure therapy vs wait list	- PTSD symptoms - Anxiety symptoms	- PTSD and anxiety symptoms improved
Lely et al., 2019	Older people with a diagnosis of PTSD (n=33)89	Narrative exposure therapy vs present-centred therapy	- PTSD symptoms	- PTSD symptoms improved
Thorp et al., 2019	Veterans with a diagnosis of PTSD (n=87)90	Prolonged exposure therapy vs relaxation training	- PTSD symptoms - Depressive symptoms	- PTSD symptoms improved
Bowland et al., 2012	Older survivors of interpersonal trauma (n=43)91	Spiritual-focused group psychotherapy vs usual care	- PTSD symptoms - Depressive symptoms - Anxiety symptoms - Physical health	- All symptoms improved
Chan et al., 2011	Older primary care patients with PTSD (n= total 1801; n =191 with PTSD)92	Collaborative care vs usual care	- Depressive symptoms - Disability	- Depressive symptoms improved
Efendi et al., 2020	Older people living in the post-earthquake Lombok area with PTSD (n=90)93	Trauma-focused CBT vs waiting list	- PTSD symptoms - Depressive symptoms - Quality of life	- All symptoms improved
Forstmeier et al., 2023	Holocaust survivors with a probable diagnosis of full or subsyndromal PTSD (n=49)94	Life review therapy vs a supportive control group	- PTSD symptoms - Depressive symptoms	- PTSD and depressive symptoms improved
Knaevelsrud et al., 2017	Having experienced a traumatic event as a child or adolescent during World War II and PTSD symptoms (n=94)95	Therapist-guided Internet-based CBT vs wait list	- PTSD symptoms - Depressive symptoms - Anxiety symptoms - Self-efficacy - Quality of life	- PTSD symptoms and quality of life improved
Browne et al., 2021	Veterans with PTSD (n=67)96	Physical activity counselling vs usual care	- PTSD symptoms - Physical and mental health - Aerobic endurance - Physical activity	- Physical activity and walking increased - Psychological health improved

Overall, psychological interventions were associated with a reduction on PTSD symptoms and showed a positive effect on reducing symptoms of depression. The study evaluating physical activity counseling showed that both physical activity and psychological health improved after the intervention. Control groups varied; most common comparisons included a waiting list control, usual care, relaxation training, supportive group, psychoeducation or person-centered therapy. Our analysis on risk of bias indicated that there were generally concerns in terms of quality of evidence in relation to randomization, selective reporting, and studies generally reporting data on small samples.

Care

Despite widespread implementation of TIC models in psychiatric and other health settings⁹⁸, the implementation of TIC into long-term care settings is in its infancy. Research documenting these efforts was scarce. A recent scoping review identified only five studies reporting implementation of TIC in these settings (all qualitative case studies with high risk of bias)⁹⁹. To date, one case series study has described outcomes of an intervention to implement TIC in geriatric hospital wards^{100, 101}, and the results suggest TIC could promote care safety and management of traumatic stress symptoms. No studies that describe efforts to implement TIC into community care settings for older adults were identified. Table 4 provides a summary of recommendations for the implementation of TIC in nursing home care settings, offering a strategic foundation for future initiatives in this area.

Table 4.

Summary of Recommendations for the Implementation of Trauma-Informed Care in Elder Care Settings

Core goals of trauma-informed models of care a	Definition	Common barriers in mainstream health and elder care settings	Strategies that may aid implementation
Promote safety	Care recipients and staff feel psychologically and physically safe	• Inadequate crisis protocols • Chemical or physical restraints • Environmental triggers • Staff not skilled in de-escalation • Assessment processes that are ‘activating’ • Staff not adequately supported • ‘One size fits all’ care	• Staff training • Improved crisis protocols • Chemical restraint deprescribing • Access to psychiatric or psychological care • Screening for trauma-related needs • Staff debriefing, self-care prioritized • Environment set up for calm, privacy, safety
Be trustworthy and transparent	Organizational operations are conducted in a transparent and predictable manner, promoting trust	• Staff turnover • Lack of resources • Environmental constraints • Lack of staff training • Staff not afforded flexibility • Poor communication • Opaque governance structures, policies and procedures	• Consistency in care providers, processes • Clear and consistent communication • Signage • Staff training • Availability of service policies, procedures for all care recipients and families
Provide peer support	Individuals with lived experienced of traumatic stress are able to engage with each other	• Stigma • Insufficient screening and assessment • Environmental constraints • Cognitive impairment • Limited staff expertise in mental health	• Access to mental health supports • Routine screening for trauma-related needs • Structures to promote peer support • Space to engage in private conversation • Support for communication difficulties
Promote collaboration and mutuality	Power differences between care providers and recipients are minimized via shared decision making	• Culture of “doing for” • Limited opportunity for choice • Limited staff time • Environmental constraints • Seclusion and restraint • Care recipients not asked for feedback	• Care recipient and / or family involvement in service governance • Clear opportunities for care recipients to provide feedback and make complaints • Strengths-based approach in which staff “do with” • Environmental change to promote collaboration between care staff and recipients • Building staff empathy (for example, through the delivery of presence care105)
Prioritize empowerment, voice, and choice	Care recipients are empowered and respected by being offered choice and autonomy in all care	• Culture of “doing for” • Limited opportunity for choice • Medicalization of care • Risk aversion • Staff not afforded flexibility • ‘One size fits all’ care	• Availability of options • Choices respected • Biopsychosocial approach to care • Opportunities for flexibility • Person-centered care
Recognize cultural, historical, and gender issues	Care services recognize and respond to culturally, historically, and gender-specific needs	• Lack of staff diversity • Limited staff expertise • Limited staff time • ‘One size fits all’ care	• Access to appropriate mental health support • Careful selection of staff members • Celebration of diversity • Culture of learning

^aPer the Substance Abuse and Mental Health Services Administration guidelines

Position statements

Cross-domain statements

Although we identified a substantial number of studies on PTSD in older adults, covering key aspects across our four domains, overall there is a notable scarcity of high-quality research specifically focused on this population. Furthermore, the majority of these studies involve samples that are not representative of the general older population. The “older” cohorts often comprise individuals from younger age ranges and typically exclude those with cognitive or somatic comorbidities. This creates a sample that does not reflect the global aging population, where a significant proportion lives with comorbidities and chronic disease. There is also a marked gap in research involving older adults from diverse settings, both in the general population and among those in various care settings. In particular, studies focusing on women, individuals with physical or cognitive disabilities (especially in long-term care), and older adults from non-Western countries are underrepresented. Consequently, the applicability of existing findings to clinical practice is limited, highlighting the need for more inclusive and representative research in this field.

Ageing mechanisms

The existing literature on PTSD and ageing mechanisms demonstrates vast heterogeneity in study designs, trauma types (e.g., sexual abuse, combat exposure, childhood maltreatment), timing (age of trauma often unknown), and PTSD assessment instruments used (CAPS, Structured Clinical Interview for DSM-5 [SCID], DSM-4/5, ICD-10, Mini International Neuropsychiatric Interview [MINI], PTSD Checklist for DSM-5 [PCL], Traumatic Experiences Inventory [TEI], etc.). These variations contribute to significant methodological inconsistencies, limiting the comparability of findings across studies. Most research has been conducted in high-income, Western countries and predominantly reports discrete factor associations rather than elucidating causal mechanisms underlying the relationship between trauma, PTSD, and ageing.

Future research is essential to identify key biopsychosocial mechanisms and their interactions, particularly those involved in epigenetic processes (e.g., DNAm and telomere lengthening) that may mediate the effects of PTSD on ageing across the life course. Clinically, screening for metabolic risk factors should be integrated into the physical and laboratory assessments of individuals with PTSD, given the high prevalence of comorbid metabolic syndromes. Inflammatory markers (e.g., C-reactive protein) and metabolic syndrome represent important intervention targets to reduce PTSD-related morbidity and mortality. Additionally, the use of epigenetic clock assessments offers a promising tool for tracking cellular ageing and evaluating the effectiveness of interventions aimed at slowing cellular ageing in individuals with traumatic stress and PTSD.

Assessment

We identified a significant lack of validation studies for PTSD screening and diagnostic tools within the general older adult population, particularly across diverse clinical and cultural settings. There is a notable absence of research involving older adults with cognitive impairment, as well as studies in non-Western or non-English speaking populations. Furthermore, there are few studies utilizing instruments based on the DSM-5 or ICD, with the CAPS-5 being the only DSM-5-based tool validated for older adults. Given this, the CAPS-5 is currently recommended for clinical practice.

Treatment

While psychological interventions demonstrate some efficacy in reducing symptoms of depression and PTSD among older trauma survivors, the number of RCTs in this population remains limited. Notably, we found no trials evaluating the clinical effectiveness of pharmacological treatments, highlighting a critical gap that warrants prioritization in future research. To advance the field, future studies should focus on large-scale RCTs that include diverse populations of older adults. Additionally, rigorous investigations into the clinical and cost-effectiveness of PTSD treatments for this age group are urgently needed.

Care

TIC models should be implemented as standard practice across mainstream health and social care settings. It is essential that health and social care providers receive training on the long-term effects of traumatic stress, methods for assessing trauma-related needs, and skills for appropriately responding to trauma disclosures. Additionally, clear pathways to mental health support for older trauma survivors must be established. Given that care providers for older adults may themselves be trauma survivors, it is crucial that they, too, have access to resources that support their resilience, well-being, and caregiving capacity. However, this implementation faces challenges, as many workforce members have limited mental health expertise and operate within resource-constrained environments, exacerbated by the medicalization of care⁹⁹.

Despite the limited evidence base, U.S. regulators mandated the implementation of TIC in skilled nursing facilities in 2019¹⁰². This mandate is grounded in the hypothesis—supported by limited evidence and research from psychiatric and other healthcare settings—that trauma has a substantial impact on the care of older people, and that TIC models could provide significant benefits in the care of older adults. In the absence of formal guidelines for delivering TIC in care settings for older adults^{9, 102–104}, we propose a series of recommendations to guide policy and practice change (summarized in Table 4)¹⁰⁵.

Integrating lived experience

To date, it is widely recognized that working with people with lived experience carries a wide range of benefits for both mental health research, clinical practice, and health-services research¹⁰⁶. Integrating lived experience knowledge with scientific knowledge can improve the quality, relevance, implementation, and impact of research¹⁰⁷. Hence, people with lived experience of trauma should be involved in all stages of future research, including setting research priorities, developing interventions and models of care, and translating findings to clinical practice and policy.

Recommendations for future research

Below are key recommendations aligned with the relevant WHO Guidelines on Integrated Care for Older People (ICOPE) guidelines and person-centred assessment for older adults (WHO, 2017)¹ and are intended to guide interventional and clinical work for older adults with trauma and PTSD.

Overarching

Researchers in the field of traumatic stress should focus on including older trauma survivors, particularly those aged 75 and older, as well as women and individuals from non-English and non-Western speaking backgrounds. High-quality studies are needed, including prospective cohorts, RCTs, and controlled time-series studies. It is essential to conduct inclusive research with a representative, heterogeneous, older population, including those with cognitive impairment and those in underrepresented cultural groups, to ensure the findings are applicable to all in clinical practice. Trauma research involving older adults should be conducted across different care settings including long-term care. Additionally, people with lived experience should be involved at all stages of the research; including input not only from trauma survivors, but also their relatives, supporters, and professionals directly involved in their care, to enhance relevance and impact.

Ageing mechanisms

There is a need for longitudinal studies, with longer-follow-up periods and sampling methodologies including more gender diverse samples and diagnostic instruments. This should aim towards elucidating the course and bidirectional nature of associations between different mechanisms and how they contribute to accelerated ageing in people with PTSD. More research on the impact of PTSD using a larger set of health outcomes is needed, including age-related diseases and indices of quality of life and daily functioning especially in those living with multimorbidity (e.g., frailty, Activities of Daily Living [ADLs], Incident Instrumental Activities of Daily Living Difficulty [IADLs], years lived in good health, end of life outcomes). Future studies should identify at risk population groups by clarifying heterogeneity in associations with gender and other structural determinants such as socio-economic status, access to healthcare access, and educational level. Future research should also examine the direct role of social support and associated constructs in accelerated ageing, as well as its potential for moderating effects on the ageing process in those with PTSD.

Assessment

More studies are needed to evaluate the psychometric validity of PTSD measures in older adults, with a significant proportion of these studies focusing on individuals from the general adult civilian population. Research focused on PTSD assessment in older adults with PTSD and co-occurring cognitive impairment is necessary. To ensure cross-cultural measurement equivalence, studies involving samples from non-Western cultures and non-English speaking samples are needed. Future research should assess measures based on the DSM-5 or ICD-10, paying close attention to characteristics of the traumatic events. Key aspects such as the type of adversity, timing, frequency, and combination of events should also be taken into account, as these factors likely influence the presentation of trauma-related symptoms.

Treatment

Large-scale RCTs are essential to determine the clinical effectiveness of first-line interventions for treating older survivors, particularly focusing on women and the general population. Additionally, there is an urgent need to evaluate and develop interventions co-produced with individuals who have lived experience of trauma. Future trials should also establish the effectiveness and safety of pharmacological treatments, with careful consideration given to polypharmacy, long-term use of psychiatric medication, possible side effects, and the potential adverse impact on older adults’ mental and physical health. The effects of trauma-focused therapies should be measured across several domains, including PTSD symptoms and other mental health outcomes, such as anxiety and quality of life. Furthermore, future research must assess the cost-effectiveness of interventions, exploring how these treatments can be integrated within mental health services and made widely accessible to older adults with PTSD.

Care

High-quality research studies, such as RCTs and controlled time-series studies, are required to develop strategies for improving the identification and management of trauma-related needs across care settings. Additionally, studies are needed to evaluate the effect of TIC implementation on various outcomes in care environments, including home, community, tertiary, and long-term care. Research must provide evidence for several care outcomes, encompassing adverse events, traumatic stress and other psychiatric symptoms, care quality indicators (such as care satisfaction and quality of life), costs, use of seclusion and restraint, and staff confidence, well-being, and burnout. Further research must address barriers and facilitators to implementation to identify effective strategies for enhancing the safety and accessibility of care for older adults with PTSD.