Deborah Brauser

March 24, 2014

ORLANDO, Florida ― Posttraumatic stress disorder (PTSD) in older adults is significantly associated with development of specific types of vascular disease, including cerebrovascular disease (CVD) and myocardial infarction (MI), new research suggests.

A study of more than 135,000 veterans older than 54 years showed that those who had PTSD were 80% more likely to have incident CVD than age-matched peers who did not have PTSD. They were also 82% more likely to have MI, 60% more likely to have peripheral vascular disease, and 56% more likely to have congestive heart failure.

Fully adjusted models showed that those with PTSD were still at 45% greater risk for CVD during 8 years of follow-up, 49% greater risk for MI, 35% greater risk for peripheral vascular disease, and 26% greater risk for congestive heart failure compared with those without PTSD.

"Frankly, the significance of these results surprised me a little bit," lead author Matthew Beristianos, from the University of California, San Francisco (UCSF), told Medscape Medical News.

"There is literature out there indicating there is a higher cardiovascular risk with PTSD, but we didn't know about these specific outcomes. And even after adjusting for all our covariates, there were close to 50% effects in 2 of the outcomes and at least 25% in the other 2," he added.

The investigators note that the study findings show that greater monitoring and treatment of PTSD is needed in older adults to prevent these types of problems over the long term.

The results were presented during an Early Investigators Posters session here at the American Association for Geriatric Psychiatry (AAGP) 2014 Annual Meeting.

Significant Risk Factor

"Although PTSD is associated with poor health outcomes in younger veterans, little is known about late-life PTSD and its association with adverse outcomes," write the researchers.

They first examined records from a random sample of 200,000 veterans who were part of the Veterans Affairs (VA) National Patient Care Database. All were 55 years of age or older.

Baseline data from 2000 to 2003 and follow-up data from 2004 to 2011 were assessed.

Veterans who had baseline diagnoses, based on diagnostic codes from the International Clarification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), of vascular-related disorders were excluded. This left a final patient sample of 138,341 (mean age, 67.8 years; 4.2% women).

The subgroup with PTSD were determined by their records showing ICD-9-CM codes for PTSD during 2 or more office visits during the baseline period.

"Unfortunately, we didn't have information on how long ago they received their diagnosis," reported Beristianos.

Unadjusted results showed that the group with PTSD had a significantly higher risk of developing all of the vascular-related disorders assessed in the ICD-9-CM than the group without PTSD.

This included a hazard ratio (HR) of 1.82 for MI (95% confidence interval [CI], 1.63 - 2.04), 1.80 for incident CVD (95% CI, 1.66 - 1.95), 1.60 for peripheral vascular disease (95% CI, 1.47 - 1.75), and 1.56 for congestive heart failure (95% CI, 1.42 - 1.72). For all disorders, P < .001.

Clear Snapshot

After adjusting for all covariates, including demographics, substance use disorders, other psychiatric disorders, and medical comorbidities such as hypertension and diabetes, all 4 vascular disorders remained a significant risk for the veterans with PTSD. They had HRs of 1.49, 1.45, 1.35, and 1.26 for MI, CVD, peripheral vascular disease, and congestive heart failure, respectively (all, P < .001).

Finally, the 8-year cumulative incidence rates were also significantly higher for all 4 adverse outcomes for the participants with PTSD than for those without (CVD: 16.1% vs 12%; peripheral vascular disease: 12.8% vs 10.7%; congestive heart failure: 11.6% vs 10%; MI: 8% vs 5.7%.)

"So we found that veterans who had late-life PTSD were at significant risk for all these outcomes longitudinally. It wasn't a cross-sectional dataset that a lot of studies have done so far to this point," said Beristianos.

The investigators admit that the results may not be generizable to younger vets or to civilians.

"Still, the study gave us a pretty clear snapshot of what's going on, at least in this patient sample," added Beristianos, noting that it also shows the importance of integrating care between psychiatrists and cardiologists and other healthcare professionals.

"This is especially important in the VA, where there is probably the largest sample of the PTSD population, along with substance abuse and depression," he said.

Beristianos added that the investigators are hoping to conduct further studies that examine these issues in other populations

Pernicious Effects

Eric Lenze, MD, geriatric psychiatrist and professor of psychiatry at Washington University School of Medicine in St. Louis, Missouri, told Medscape Medical News that the study is a nice addition to the literature.

Dr. Eric Lenze

"It adds to a fair amount of data about the long-term, pernicious effects of PTSD ― not just for suffering and disability but also for long-term health and cognitive function," he said.

Dr. Lenze, who was not involved with this research, is also the research committee chair for the AAGP. He noted that investigators from UCSF recently published "a very high profile" study suggesting that PTSD increases the risk for dementia.

"To me as a geriatric psychiatrist, this [current study] highlights the importance of trying to get good treatment for PTSD at any age. Unfortunately, there's been a dearth of research investigating how to treat PTSD in older adults," he said.

He added that what research there has been has suggested that the same type of exposure-based cognitive behavioral therapy techniques that seem to work well in younger adults also work well in those who are older, and they are well tolerated.

However, "it's my hope that we see more treatment advances in this area because it's a very tough disorder to treat sometimes," said Dr. Lenze.

The study was funded by a grant from the US Department of Defense. The study authors have disclosed no relevant financial relationships.

American Association for Geriatric Psychiatry (AAGP) 2014 Annual Meeting. Abstract EI-01. Presented March 16, 2014.

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