aging veterans: health outcomes and considerations for care

Health Outcomes + Considerations for Care

Aging VeteransVETERANS + BEHAVIORAL HEALTH

WEBINAR SERIES

Swords to PlowsharesInstitute For Veteran Policy

Presenters:Michael Blecker, Executive Director

Amy Fairweather, Director, Institute for Veteran PolicyJanice Yee, Geriatrics Specialist

8/26/15

What Will We Cover? Demographics of Aging Veterans

Health Outcomes Related to Military Service

The Vietnam Generation: Legacy of neglect

Housing + Clinical Outcomes of Aging Veterans: A community perspective

Housing: Permanent

Supportive + Transitional

Employment +Job Training

Health + Social Services

Institute for Veteran Policy

WomenVeteransProgram

Legal Servicesfor Veterans

With Disabilities

An Overview of Services

Aging Veterans Demographics - U.S.

Veterans aged 55+ represent 66% (13.9 million) of the veteran population in the U.S. 22% are over 75 years old.

Ages 20-34

9%

Ages 35-5427%

Ages 55+64%

(Vetpop, 2015)

LATE-ONSET STRESS SYMPTOMATOLOGY (LOSS) Hypothesized phenomenon among older veterans who

a) experienced highly stressful combat events in early adulthood;

b) functioned successfully throughout their lives, with no chronic stress-related disorders; but

c) begin to register increased combat-related thoughts, feelings, reminiscences, memories, or symptoms commensurate with the changes and challenges of aging, sometimes decades after their combat experiences.

LOSS is distinct from PTSD.

(NCPTSD, 2009)


POST-TRAUMATIC STRESS DISORDER (PTSD) is associated with high rates of morbidity and mortality and is one of the most common sequelae in veterans.

Many older veterans find they have PTSD symptoms even 50 or more years after their wartime experience.

PTSD symptoms can worsen later in life.

Vietnam veterans:

• Up to 30% lifetime prevalence of combat-related PTSD.

• 10% to 15% had the disorder 15 years or longer after Vietnam.

World War II and Korean veterans:

• PTSD prevalence remained as high as 12% even 45 years after combat.

(Dohrenwend et al, 2006; NCPTSD, 2015)


PTSD AND HEALTH PTSD is associated with greater healthcare use and an increased

risk of developing a wide range of medical conditions in veterans.

Vietnam veterans with combat-related PTSD report more current and chronic health problems than combat veterans without PTSD.

Older veterans with PTSD symptoms significantly more likely to report:

• poor general health: cardiovascular disease, diabetes, gastrointestinal disease, fibromyalgia, chronic fatigue syndrome, musculoskeletal disorders, autoimmune disease.

(Friedman & Schnurr, 1995; Schnurr et al, 2000; Durai et al, 2011)



SUICIDEOLDER VETERANS WITH PTSD SYMPTOMS SIGNIFICANTLY MORE LIKELY TO REPORT:

little or no social support. higher prevalence of mental distress, death wishes,

and suicidal ideation.

OLDER VETERANS ARE AT INCREASED RISK OF SUICIDE: TWO-THIRDS WHO COMPLETE SUICIDE ARE AGE 50 OR OLDER.

(Durai et al, 2011; Bagalman, 2013)


PTSD AND MEMORY LOSS Memory impairments in PTSD appear to become more

prominent with aging.

Compared to older veterans without PTSD, older combat veterans with PTSD show a greater decrement in aspects of memory.

(Wilmoth & London, 2011)


PTSD AND

DEMENTIA

PTSD exacerbated upon onset of cognitive impairment.

Those diagnosed with PTSD more than 2x as likely to develop dementia.

DEPRESSIONAND

DEMENTIA

2x as likely to develop incident dementia compared with those with no depression.

(Mittal et al, 2001; Yaffe et al, 2010; Byers et al, 2012)


TRAUMATIC BRAIN INJURY AND DEMENTIA

Traumatic brain injury increases the risk of dementia in veterans aged 55 and older:

(Barnes et al, 2014)

16% of those with TBI developed dementia during the study period, compared with 10% of those without TBI.

Age of onset for those who developed dementia was about two years earlier for those with TBI than those without.

PTSD and TBI have been shown to be risk factors for AD.

Brain injury may cause earlier onset or acceleration of AD.

Prospective study of World War II veterans found that moderate and severe head injury was associated with a 2- to

4-fold increase in risk of AD and other dementias.

Health Outcomes Related to Military ServiceALZHEIMER’S DISEASE (AD)

(Plassman et al, 2000; Johnson et al, 2012; Weiner, et al, 2013)


DIABETES1 in 4 veterans at VA has diabetes

compared to1 in 10 Americans has diabetes

Diabetes25%

No Di-abetes75%

Veterans

Diabetes9%

No Diabetes91%

Non-Veterans


DIABETESRISKS: Higher rate of overweight and obesity than the general

population: More than 70% of patients in VA facilities are overweight or obese.

Social disparities: Lower incomes, limited access to high-quality, healthy food.

Agent Orange/herbicides.

(VHA, 2015)


AGENT ORANGE was an herbicide and defoliant used by the military during the Vietnam War as part of its chemical warfare program.

VA AND FEDERAL LAW presumes that certain diseases are a result of exposure to these herbicides. Through this process, the list of 'presumptive' conditions are:

throat cancer, acute/chronic leukemia, Hodgkin's lymphoma + non-Hodgkin's lymphoma, prostate cancer, lung cancer, colon cancer, soft tissue sarcoma, respiratory cancers, multiple myeloma, type II diabetes, chloracne, porphyria cutanea tarda, peripheral neuropathy, chronic lymphocytic leukemia, B cell leukemia, such as hairy cell leukemia, Parkinson's disease and ischemic heart disease, and spina bifida in children of veterans exposed to Agent Orange as conditions associated with exposure to the herbicide.

Homeless Aging Veterans

50% of Homeless Veterans are Age 51 or Older, Compared to 19% Homeless Non-Veterans

VULNERABILITY High rates of hospitalizations and age-adjusted mortality. More rapid disease course, leading to earlier morbidity. Place increased demands (vs. non-homeless older veterans) on

a health system when enrolled in a medical home model, accessing primary, mental health, and substance abuse care more frequently.

(Adams et al, 2007; O’Toole et al, 2013)

The Vietnam Veteran Generation

Presented by:Michael Blecker

Executive Director

Swords to Plowshares

1. The Poverty Draft

2. Decade of Neglect

3. Health and Economic Consequences

THE LEGACY OF NEGLECT


Social isolation

Divorce

Community neglect

Unemployment

Homelessness

Mental illness

Physical disabilities


THE POVERTY DRAFT 76% of the men sent to Vietnam were from lower

middle/working class backgrounds.

Draft deferments were for college attendance and a variety of civilian occupations that favored middle- and upper- class whites.

The vast majority of draftees were poor, under-educated, and urban-blue-collar workers or unemployed.

(Encyclopedia of the Vietnam War, 1998)


PROJECT 100,000 (1966-1971)

Program devised by the Department of Defense to ease recruitment standards for the Army, promoted to allow inner-city youth and poor young men from rural areas to join the military as part of their climb out of poverty.

Eventually criticized for making them a significant segment of the combat personnel fighting in Vietnam.


PROJECT 100,000 (1966-1971)Casualty rates among these soldiers were twice those of other entry categories.

Few Project 100,000 inductees received training that would aid their military advancement or create better opportunities for civilian life.

Comparisons between Project 100,000 participants and their non-veteran peers: Veterans were more likely to be unemployed, have a significantly lower level of education, lower income, and to become divorced.

(Laurence et al, 1989)


“A White Man’s War,

A Black Man’s

Fight”

– Martin Luther

King, Jr.

Black youths represented a disproportionate share of early draftees.

41% of Project 100,000 were African American.

African Americans were a disproportionate number of combat troops: • 1/3 who enlisted served in combat arms.

• 40% of African Americans in Project 100,000 drew combat assignments.

• 1961-1966: African Americans made up 20% of all combat-related deaths.

(Encyclopedia of the Vietnam War, 1998)


DECADE OF NEGLECT

“Last Hired, First Fired”

Vietnam service acted as a negative screening device in the labor market as Americans reacted to an unpopular war and common conceptions about veterans.

(Schwartz , 1986; Angrist , 1991; Ruger, Wilson, & Waddoups, 2002)


DECADE OF NEGLECT

Increased migration, lack of residential stability.

Disintegration to community. High divorce rates. Social isolation.

• Low levels of social support in the first year after discharge.

(Rosenheck & Fontana, 1994; Conley, 2011)


DECADE OF NEGLECT

Lack of federal support: Not given same care as WWII.

Lack of support from WWII veteran service organizations.

Not seen as deserving as prior era. GI bill inadequate.


AGENT ORANGE1977: Veterans began to file claims to the VA.

Claims denied unless they could prove condition began when they were in service or within one year of discharge.

1984: Class-action suit against seven chemical companies settled out of court.

1991: Agent Orange Act—thousands of VA claims, very few compensated.

2010: VA expanded presumptions—brought on 260,000 new Agent Orange claims.

(Chambers et al, 1999; Fleischer et al, 2001; VA, 2014)


WHERE WE ARE NOWPost-Traumatic Stress Disorder 40 Years Later

271,000 Vietnam theater veterans have current full PTSD, one-third of whom have current major depressive disorder. (National Vietnam Veterans Longitudinal Study.)

Demand for treatment of PTSD among Vietnam veterans has increased steadily. (Hermes et al, 2015)


Homelessness

Nearly half of homeless veteran population.

Hardest to place: unsheltered, chronically homeless and those with severe medical and mental health issues, presenting VA with greatest challenges in ending homelessness.(NCHV, 2015)

WHERE WE ARE NOW


SWORDS TO PLOWSHARES FINDINGS

Veterans are older than their chronological age.

Pre-disposed for a variety of health issues impacted by their military service related injuries.

Life-limiting illness, frailty or disability associated with chronic disease, aging or injury.

Housing and Clinical Treatment Outcomes: A Community Perspective

Presented by:Janice YeeGeriatrics SpecialistSwords to

Plowshares

1. Increased demand for housing.

2. Building community and support.

3. Access to VA services.

4. Access to permanent housing.


Increasing demand for transitional housing for homeless and disabled veterans 60 years and older:

- Mobility, medical, mental health, and cognitive challenges of this veteran population.

- Challenges of accommodating these veterans into transitional housing.


Building community and support among veterans to address isolation and depression and to stimulate cognition.

- Interacting with veteran staff.

- Forming Vet to Vet groups.

- Music, films, games, day trips.


Access to VA:

- Medical and behavioral health appointments.

- Specialized care: Gerontology; Neuro Psych evaluations; physical therapy (including walking devices; electric scooters/wheelchairs).

- Social services: Medical Van transport; assistance with Aide and Attendance pension.


Options for those who can live independently:

Supportive subsidized housing.

Subsidized senior apartments.

State Veterans’ Homes.

Access to permanent housing:


Options for those who are unable to live

independently:

Board and Care/Assisted living facilities.

Community Living Center (CLC) at San Francisco VA.

State Veterans’ Homes.

Access to permanent housing:

What Questions Do You Have?

Thank You for Your Attendance

Swords to PlowsharesInstitute for Veteran Policy1060 Howard StreetSan Francisco, CA 94103

(415) 252-4788

[email protected]

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