Co-Occurring Mental and Physical Health Conditions Among Older Adults With and Without Post-traumatic Stress Disorder: A Case Control Study

Abstract

Objectives

Rates of post-traumatic stress disorder (PTSD) among older adults range from 0.4%–4.5%. Research examining PTSD in adults has demonstrated numerous associations between physical and mental health conditions; however, these are less well characterized in older adults. The current study aimed to identify base rates of such conditions among older adults with and without a history of PTSD.

Method

In a case control design using the National Alzheimer’s Coordinating Center Uniform Data Set, adults 65 years or older from the United States who endorsed either the presence or absence of PTSD were matched by age to assess between-group differences (N = 472; 236 pairs). We examined differences across self-reported sociodemographics and physical health, mental health, and substance use histories.

Results

More participants with a history of PTSD identified as Hispanic, non-white, non-married, and functionally independent. Compared to individuals without a history of PTSD, significantly more individuals with a history of PTSD had histories of depression, anxiety, substance abuse, Parkinson’s disease, seizures, insomnia, and TBI. Among participants without PTSD history, only 14.7% reported a history of TBI, compared to 41.1% of individuals with PTSD history.

Conclusions

Findings showed expected trends toward worse physical and mental health among older adults with self-reported PTSD. There was a striking difference in the frequency of TBI history between participants with and without PTSD. These findings underscore a need to assess for PTSD among older adults, particularly those reporting a history of TBI.

Keywords

PTSD older adults comorbidity case control

Introduction

Estimates suggest that about 50% of adults over age 50 in the United States have past exposure to at least 1 traumatic event during their lifetime,¹ and rates of current post-traumatic stress disorder (PTSD) among older adults range from 0.4%–4.5%.^2,3 Furthermore, there is existing evidence supporting the co-occurrence of PTSD with other physical and mental health conditions, with multiple proposed explanations for these relationships, including significant symptom overlap between PTSD and other psychiatric conditions, the use of alcohol and other substances in an effort to reduce distress associated with PTSD symptoms that can evolve into a substance use disorder, and the potential that broader physiological and behavioral changes associated with PTSD may impact the development of other conditions (eg, cardiovascular disease).⁴ Further investigation to better understand the base rates of co-occurrence has the potential to inform screening and intervention efforts, such as through primary care settings, to improve identification of individuals at risk for developing future physical health conditions.⁵

PTSD and Co-occurring Physical Health Conditions in Adults

Physical health conditions are prevalent among adults diagnosed with PTSD.⁶ Risks related to cardiometabolic and cardiovascular disease^4,7,8 are particularly notable; however, studies have also examined the association between PTSD and autoimmune disease,⁹ insomnia,¹⁰ chronic pain,¹¹ arthritis, digestive conditions,¹² and central nervous system conditions (eg, Parkinson’s disease, seizures, traumatic brain injury (TBI)^13-15). Not only are many of these co-occurring physical conditions chronic and stress-related,¹⁶ there is also evidence to suggest that PTSD symptomology may worsen co-occurring medical conditions through medical risk factors (eg, cardiovascular history) and influence on health behaviors (eg, physical activity).¹⁷

PTSD and Co-occurring Mental Health Conditions in Adults

Rates of co-occurrence between PTSD and other mental health conditions are extremely high, with estimates that more than 90% of adults with a current or lifetime PTSD diagnosis also meet criteria for a mood or anxiety disorder.¹⁸ PTSD is also highly comorbid with substance use disorders, particularly alcohol use disorder (AUD), with lifetime prevalence ranging from 26 to 52%.¹⁹ Diagnostic challenges associated with the inclusion of non-specific mood symptoms in PTSD diagnostic criteria and overlap in symptoms between mental health conditions have made it more difficult to establish accurate diagnoses in clinical and research settings.²⁰

PTSD and Co-occurring Physical Health Conditions in Older Adults

Although less extensive compared to the body of literature examining co-occurring conditions in adults, literature examining associations between PTSD and physical and mental health conditions in older adults (65+) similarly reveals associations between PTSD and numerous conditions, including sleep disorders, gastrointestinal conditions, cancer,²¹ as well as chronic obstructive pulmonary disease (COPD).²² Physiological changes secondary to PTSD (eg, autonomic reactivity), engaging in unhealthy behavior (eg, substance use²¹), and diminished emotional wellbeing²² have been implicated as contributors to the development of these physical health conditions. Relatedly, PTSD appears to be a correlate of accelerated aging at various physiological levels (eg, cellular), illustrating the influence of PTSD on physical health through detrimental biological aging processes.^8,23

PTSD and Co-occurring Mental Health Conditions in Older Adults

Although more limited than the research focused on adults, a recent review focused on the association between PTSD and co-occurring mental health conditions in older adults (60+) identified multiple studies that support a high prevalence of co-occurrence between PTSD and several psychiatric conditions, most commonly: major depressive disorder (14.7%–62.5%) and alcohol use disorder (12.5%–63.4%), along with various types of anxiety disorders (eg, generalized anxiety disorder, 8.8%–30.0%).²⁴ Of note, the majority of this research has focused on older adult Veterans,²⁵ which has limited the generalizability of these findings and highlights the importance of extending this work into non-Veteran community samples.

Study Aims

Research examining PTSD in adults has demonstrated numerous associations between physical and mental health conditions; however, these factors are less well characterized in older adults. The current study aimed to examine the frequency of physical and mental health conditions among older adults in the National Alzheimer’s Coordinating Center Uniform Data Set (NACC UDS) with and without a history of self-reported PTSD with the goal of identifying base rates of the co-occurrence of physical and mental health conditions and PTSD using a large national sample and case-control design. Based on existing literature in adults and older adults, we hypothesized that older adults with a history of PTSD would have higher rates of co-occurring mental and physical health conditions compared to those without PTSD. Additionally, given evidence for racial/ethnic and sex differences in rates of PTSD and co-occurring physical health conditions,^26,27 we planned to examine differences in the occurrence of PTSD by these demographic factors.

Method

Participants and Design

We submitted a request for UDS data through the National Alzheimer’s Coordinating Center (NACC) on June 30, 2023. Institutional Review Board approval from participating Alzheimer’s Disease Research Centers was obtained for data collection procedures. Since 2005, approximately 30 Alzheimer’s Disease Research Centers (ADRCs) have contributed to the NACC UDS, which is a database of standardized cognitive, behavioral, and functional participant evaluations; a full description is available elsewhere.²⁸

The provided UDS data included 47,772 participants through March 2023. Notably, 33,070 (69.2%) participants were missing self-report PTSD history data. Among those missing data, 32,893 (68.9%) participants completed an earlier version of the UDS (ie, version 1.2 – 2.0) which did not include a specific PTSD query. Only 177 (0.4%) of participants’ responses were listed as “unknown” in the dataset. Selection criteria included adults 65 years or older, for whom English was their primary language, and endorsement of either the presence or absence of prior physician diagnosis or treatment for PTSD. Application of these criteria resulted in an overall sample of 9738 participants, 236 (2.4%) of whom self-reported a prior history of PTSD. Participants with self-reported PTSD were matched to participants without a self-reported history of PTSD by age. We opted not to match along additional sociodemographic variables (eg, sex, race, ethnicity) as we were interested in assessing between-group differences across these variables after controlling for age. This resulted in an overall sample of 472 participants, or 236 matched pairs.

Comparative Analyses

We examined between-group differences across sociodemographic, physical health variables, and mental health and substance use histories. Sociodemographic variables included self-reported sex, ethnicity, race, years of education, marital status, and level of functional independence. The following variables were obtained via participant self-report, or co-participant report.

Physical Health Variables

We included numerous self-reported physical health history variables. Among those associated with cardiovascular health, we examined: history of heart attack/cardiac arrest, atrial fibrillation, stroke, diabetes, hypertension, and hypercholesterolemia. We also examined central nervous system conditions, including Parkinson’s disease, seizures, and TBI. We examined the following modifiable risk factors for cognitive impairment: vitamin B12 deficiency, thyroid disease, sleep apnea, and insomnia.

Mental Health and Substance Use Variables

We included reported histories of prior physician diagnosis or treatment for bipolar disorder, schizophrenia, depression, anxiety, and obsessive compulsive disorder (OCD). A condition was considered recent if the participant reported diagnosis or treatment in the past year and remote if diagnosis or treatment was more than 1 year ago and either the condition resolved or treatment was not currently ongoing. Self-reported history of current (past 3 months) and remote tobacco, alcohol, and other substance use was also included.

T-tests or chi-square tests were used to assess for between group differences. Alpha level was 0.05. Effect sizes were reported as either Cohen’s d or Cramer’s V. Cohen²⁹’s d effect sizes were interpreted in accordance with commonly used guidelines (0.2 = small, 0.5 = medium, 0.8 = large). Cramer’s V values of 0.1, 0.3, and 0.5 corresponded to small, medium, and large effect sizes.³⁰ SPSS (version 28.0) was used to conduct case-matching and between-group comparisons.

Results

Sociodemographic Differences

Sociodemographic differences are displayed in Table 1. There were not statistically significant between-group differences in education or sex. However, there were statistically significant between-group differences in ethnicity, race, marital status, and functional independence with small to medium effect sizes (Cramer’s V, 0.19 to 0.28). The group comprised of participants with a self-reported history of PTSD included greater proportions of individuals identifying as Hispanic (9.3% vs 3.0%), non-white (25.8% vs 15.7%), non-married (37.7% vs 26.7%), and functionally independent (81.4% vs 57.2%).

Table 1.

Demographic Differences Among Older Adults (Ages ≥65 years) With and Without Posttraumatic Stress Disorder.

	No PTSD (n = 236)	PTSD (n = 236)
	Mean (SD)	Mean (SD)	t	P	Cohen’s d	95% CI
Age	71.7 (4.9)	71.7 (4.9)	0.00	1.00	0.00	−0.18 – 0.18
Education (years)	18.9 (14.3)	17.1 (9.7)	1.62	0.11	0.15	−0.03 – 0.33
	N (%)	N (%)	χ²	P	Cramer’s V
Sex
Women	123 (52.1)	108 (45.8)	1.90	0.17	0.06
Men	113 (47.9)	128 (54.2)
Ethnicity			11.50	<0.01	0.16
Hispanic	7 (3.0)	22 (9.3)
Non-Hispanic	229 (97.0)	211 (89.4)
Unknown	0 (0.0)	3 (1.3)
Race			19.93	<0.01	0.21
White	199 (84.3)	175 (74.2)
Black or African American	21 (8.9)	44 (18.6)
American Indian or Alaska Native	1 (0.4)	7 (3.0)
Native Hawaiian or other Pacific Islander	0 (0.0)	0 (0.0)
Other	2 (0.8)	3 (1.3)
Unknown	0 (0.0)	2 (0.8)
Marital status			16.45	0.01	0.19
Married	173 (73.3)	147 (62.3)
Widowed	21 (8.9)	18 (7.6)
Divorced	27 (11.4)	47 (19.9)
Separated	2 (0.8)	4 (1.7)
Never married (or annulled)	7 (3.0)	14 (5.5)
Living as Married/Domestic Partner	1 (0.4)	6 (2.5)
Other or unknown	5 (2.1)	1 (0.4)
Functional independence			36.13	<0.01	0.28
Independent	135 (57.2)	192 (81.4)
Assistance with Complex Activities	60 (25.4)	34 (14.4)
Assistance with Basic Activities	21 (8.9)	6 (2.5)
Dependent	10 (4.2)	2 (0.8)
Unknown	10 (4.2)	2 (0.8)

Mental Health History Differences

Mental health history differences are displayed in Table 2. There were not statistically significant between-group differences in the proportion of participants with bipolar disorder, schizophrenia, or OCD. However, there were statistically significant between-group differences in recent and remote depression, remote depressive episodes, and recent and remote anxiety history with small to medium effect sizes (Cramer’s V, 0.12 to 0.32). The group comprised of participants with a self-reported history of PTSD included greater proportions of individuals with depression in the past 2 years (46.2% vs 35.2%), remote depressive episodes (59.3% vs 28.0%), and anxiety (49.2% vs 25.0%).

Table 2.

Differences Among Older Adults (Ages ≥65 years) With and Without Posttraumatic Stress Disorder in Psychological History.

	No PTSD (n = 236)	PTSD (n = 236)
	N (%)	N (%)	χ²	P	Cramer’s V
Bipolar disorder			3.95	0.27	0.09
Recent	1 (0.4)	5 (2.1)
Remote	2 (0.8)	3 (1.3)
Unknown	0 (0.0)	1 (0.4)
Schizophrenia			1.82	0.61
Recent	4 (1.7)	1 (0.4)
Remote	2 (0.8)	2 (0.8)
Unknown	1 (0.4)	1 (0.4)
Depression (in past 2 years)			7.05	0.03	0.12
Yes	83 (35.2)	109 (46.2)
Unknown	2 (0.8)	4 (1.7)
Depression episodes (>2 years prior)			47.44	<0.01	0.32
Yes	66 (28.0)	140 (59.3)
Unknown	8 (3.4)	6 (2.5)
Anxiety			21.29	<0.01	0.26
Recent	49 (20.8)	104 (44.1)
Remote	10 (4.2)	12 (5.1)
Unknown	5 (2.1)	2 (0.8)
Obsessive compulsive disorder			4.71	0.20	0.10
Recent	2 (0.8)	8 (3.4)
Remote	0 (0.0)	1 (0.4)
Unknown	2 (0.8)	2 (0.8)

Substance Use Differences

Substance use differences between participants with and without a self-reported history of PTSD are displayed in Table 3. There were not statistically significant between-group differences in the proportion of participants with respect to tobacco use history. Alcohol consumption in the past 3 months differed between groups; however, this statistically significant difference was a result of a disproportionate number of participants with missing data in the no PTSD group (4.7%). There were statistically significant between-group differences in frequency of alcohol use, alcohol abuse, and other abused substances with small effect sizes (Cramer’s V, 0.16 to 0.23). The group comprised of participants with a self-reported history of PTSD included smaller proportions of individuals reporting daily alcohol use (13.6% vs 23.3%). In contrast, the group comprised of participants with a self-reported history of PTSD included greater proportions of individuals with a history of alcohol abuse (16.1% vs 8.4%) and other abused substances (7.2% vs 1.2%).

Table 3.

Differences Among Older Adults (Ages ≥65 years) With and Without Posttraumatic Stress Disorder in Substance Use.

	No PTSD (n = 236)	PTSD (n = 236)
	Mean (SD)	Mean (SD)	t	P	Cohen’s d	95% CI
Tobacco use
Years smoking (years)	13.0 (25.6)	12.9 (20.3)	0.04	0.97	0.00	−0.17 – 0.18
	N (%)	N (%)	χ²	P	Cramer’s V
Tobacco use
Use in the past 30 days*	14 (5.9)	14 (5.9)	1.00	0.61	0.05
Alcohol use
Any alcohol consumption in the past 3 months**	142 (63.1)	143 (60.6)	11.57	<0.01	0.16
Frequency of alcohol consumption in past 3 months***			23.84	<0.01	0.23
Less than 1x/month	16 (6.8)	20 (8.5)
About 1x/month	13 (5.5)	21 (8.9)
About 1x/week	23 (9.7)	36 (15.3)
A few times a week	34 (14.4)	34 (14.4)
Daily or almost daily	55 (23.3)	32 (13.6)
Unknown	83 (35.2)	93 (39.4)
Alcohol abuse			12.48	<0.01	0.16
Recent	6 (2.5)	3 (1.3)
Remote	14 (5.9)	35 (14.8)
Unknown	6 (2.5)	2 (0.8)
Other substances			11.99	<0.01	0.16
Other abused substances	2 (0.8)	3 (1.3)
	1 (0.4)	14 (5.9)
	4 (1.7)	3 (1.3)

Note: *1 participant in the no PTSD group was missing data; **11 participants in the no PTSD group were missing data.

Physical Health History Differences

Physical health history differences are displayed in Table 4. There were not statistically significant between-group differences in the proportion of participants with heart attack/cardiac arrest, atrial fibrillation, stroke, diabetes, hypertension, hypercholesterolemia, vitamin B12 deficiency, thyroid disease, or sleep apnea. However, there were statistically significant between-group differences in Parkinson’s disease, seizures, TBI, and insomnia with small to large effect sizes (Cramer’s V, 0.12 to 0.56). The group comprised of participants with a self-reported history of PTSD included greater proportions of individuals with Parkinson’s disease (2.1% vs 0.4%), seizures (5.5% vs 3.4%), TBI (41.1% vs 0.0%), and insomnia (30.5% vs 19.9%).

Table 4.

Differences Among Older Adults (Ages >65 years) With and Without Posttraumatic Stress Disorder in Physical Health History.

	No PTSD (n = 236)	PTSD (n = 236)
	N (%)	N (%)	χ²	P	Cramer’s V
Heart Attack/Cardiac arrest			2.58	0.46	0.07
Recent	1 (0.4)	4 (1.7)
Remote	10 (4.2)	13 (5.5)
Unknown	2 (0.8)	1 (0.4)
Atrial fibrillation			0.65	0.89	0.04
Recent	17 (7.2)	13 (5.5)
Remote	5 (2.1)	6 (2.5)
Unknown	2 (0.8)	2 (0.8)
Stroke			1.04	0.79	0.05
Recent	2 (0.8)	4 (1.7)
Remote	5 (2.1)	7 (3.0)
Unknown	2 (0.8)	2 (0.8)
Parkinson’s Disease			7.18	0.03	0.12
Yes	1 (0.4)	5 (2.1)
Unknown	7 (3.0)	1 (0.4)
Seizures			8.68	0.03	0.14
Recent	3 (1.3)	3 (1.3)
Remote	5 (2.1)	10 (4.2)
Unknown	7 (3.0)	0 (0.0)
Traumatic brain injury			164.74	<0.01	0.59
Recent	0 (0.0)	14 (5.9)
Remote	0 (0.0)	83 (35.2)
Unknown	74 (31.4)	3 (1.3)
Diabetes			1.93	0.59	0.06
Recent	28 (11.9)	38 (16.1)
Remote	4 (1.7)	5 (2.1)
Unknown	1 (0.4)	1 (0.4)
Hypertension			3.10	0.38	0.08
Recent	111 (47.0)	127 (53.8)
Remote	7 (3.0)	7 (3.0)
Unknown	1 (0.4)	0 (0.0)
Hypercholesterolemia			2.54	0.47	0.07
Recent	122 (51.7)	132 (55.9)
Remote	7 (3.0)	10 (4.2)
Unknown	3 (1.3)	1 (0.4)
Vitamin B12 deficiency			3.74	0.29	0.09
Recent	14 (5.9)	25 (10.6)
Remote	5 (2.1)	5 (2.1)
Unknown	11 (4.7)	8 (3.4)
Thyroid disease			4.41	0.22	0.10
Recent	37 (15.7)	52 (22.0)
Remote	3 (1.3)	6 (2.5)
Unknown	3 (1.3)	3 (1.3)
Sleep apnea			5.35	0.15	0.11
Recent	56 (23.7)	73 (30.9)
Remote	5 (2.1)	5 (2.1)
Unknown	22 (9.3)	12 (5.1)
Insomnia			9.24	0.03	0.14
Recent	46 (19.5)	68 (28.8)
Remote	1 (0.4)	4 (1.7)
Unknown	4 (1.7)	1 (0.4)

Post-Hoc TBI Analysis

Given the considerable between-group difference in self-reported history of TBI, we conducted a post-hoc chi-square test using the full sample (N = 9738) to assess whether this difference was secondary to the case-control selection procedure or present in comparison to a larger sample of participants without a self-reported history of PTSD. Results of the chi-square test were statistically significant χ² = 124.77, P < 0.001. Among participants without a self-reported history of PTSD, only 14.8% (n = 1379/9417) reported a history of TBI, as compared to 41.6% (n = 97/233) of individuals with a self-reported history of PTSD. However, the magnitude of this difference was smaller than that of the case-control comparison (Cramer’s V = 0.11 vs 0.59).

Discussion

This study compared the frequency of mental health and physical health conditions by PTSD status in a large civilian sample of older adults residing in the U.S. Using a case-control procedure which matched participants by age, there were significantly greater proportions of individuals with a self-reported history of PTSD who identified as Hispanic, non-white, non-married, and functionally independent. Findings showed expected trends toward worse physical and mental health among participants with self-reported PTSD, which appears consistent with other community-based estimates.³¹ Notably, there was a striking difference in the frequency of self-reported history of TBI between older adults with (41.1%) and without (0.0%) PTSD.

The greater relative frequency of TBI among older adults with PTSD was somewhat expected¹⁴; however, the magnitude of this difference was staggering and has important implications for management of older adults with PTSD. TBI, including mild forms, increases the risk for PTSD in civilians and even more so in Veterans.¹⁴ A history of mental health disorder, injury mechanism, and social determinants of health are all associated with increased risk for worse outcome following TBI.³² For example, Medicare beneficiaries showed a significantly increased risk of PTSD following TBI while controlling for various mental and physical health covariates,³³ and older adult Veterans with TBI were more likely to report current PTSD symptoms compared to those without TBI.³⁴ Notably, we cannot draw causal conclusions based on the present results or the limited literature on older adults specifically; however, these observations underscore an important relationship to consider in the mental and physical health care of older adults with PTSD. Taken together, these findings underscore a critical need to assess for PTSD among older adults, particularly among those reporting a history of TBI.

Results regarding associations between PTSD and demographic differences are largely consistent with the literature. The greater prevalence of PTSD among participants identifying as non-married, non-white, and Hispanic, and the absence of an association with education has been reported elsewhere.³⁵ However, our results diverge from existing research in that older adults with PTSD reported functional independence at a greater frequency than those without PTSD, which stands in contrast to research describing an association between PTSD and disability or functional impairment.³⁵ Given the association between PTSD and physical health conditions such as cardiovascular disease,^4,7 it may be that worse physical health status, more so than PTSD, is interfering with functional independence among older adults.³⁶

The co-occurrence of PTSD and mental and physical health conditions observed in this sample is supported by similar findings described in research reporting on older adults^21,22 and adults generally.^6,9,16,18 Higher prevalence of Parkinson’s disease, seizures, and insomnia in the PTSD group is consistent with existing research on adults.^10,13,15 The absence of differences in some physical health conditions – particularly cardiovascular factors – was unexpected.^4,7 While there were not statistically significant between-group differences, there were greater numbers of individuals with PTSD reporting a recent history of multiple conditions, signifying greater physical health burden: heart attack/cardiac arrest (1.7% vs 0.4%), stroke (1.7% vs 0.8%), diabetes (16.1% vs 11.9%), hypertension (53.8% vs 47.0%), hypercholesterolemia, (55.9% vs 51.7%), vitamin B12 deficiency (10.6% vs 5.9%), thyroid disease (22.0% vs 15.7%), and sleep apnea (30.9% vs 23.7%). The comorbidity of PTSD and these physical conditions in this dataset may be due to theorized mechanisms like HPA axis dysregulation,³⁷ accelerated cellular aging,^8,23 or early life trauma exposure.³⁸

Complexity of PTSD in Older Adults

Complications inherent to aging underscore the extent to which the presence of PTSD amplifies challenges facing older adults. PTSD is infrequently acknowledged by older adults or recognized by their healthcare providers. Several factors may account for under recognition and missed diagnosis: (1) underreporting of symptoms driven by limited insight or difficulty understanding the relationship between symptoms and psychological trauma, (2) higher likelihood of reporting somatic problems vs mood changes in the setting of trauma, and/or (3) stigma.³⁷ Additionally, avoidant behavior, which can include avoidance of memories, thoughts, or emotions associated with the traumatic event, is a primary symptom of PTSD; this symptom itself may contribute to underreporting of symptoms and missed diagnosis. These factors are compounded by inaccurate discrimination among co-occurring physical, mental, and cognitive conditions that are highly prevalent in older adult populations.³⁹

Limitations

The current study includes several important limitations.⁴⁰ First, PTSD diagnosis was based on the participant’s self-report of prior physician diagnosis or treatment for PTSD and this information was not corroborated with medical records, nor was PTSD severity identified.⁴¹ Endorsement of physical and mental health conditions, including TBI, was also based on self-report without medical record corroboration. The use of self-report has the potential to introduce bias including over- and under-endorsement, which is a particular concern when assessing mental and physical health.⁴² A considerable number of NACC UDS participants (68.9%) completed an earlier version of the UDS (1.2 – 2.0) which did not include a self-report query regarding PTSD. For analyses involving mental health history, sample sizes for low base rate conditions such as bipolar disorder and schizophrenia were not sufficiently powered, limiting interpretation of these results. The UDS 3.0 categorized TBI injury severity according to injuries with or without loss of consciousness and did not conform to standardized diagnostic criteria that would have allowed for more specific severity identification (eg, mild, moderate, severe⁴³). Additionally, more than 30% of participants without PTSD had an “unknown” status with respect to TBI history; if a sizeable proportion of these participants have a prior history of TBI, this would temper the magnitude of the between-group difference. The data also do not capture broader social determinants of health (eg, neighborhood disadvantage, access to resources), many of which are associated with PTSD and other mental health conditions.⁴⁴

Future Directions

To increase support of the associations found in this work, future studies should include medical record corroboration of past and current physical and mental health conditions. It would be beneficial to incorporate objective measures of health when possible (eg, recent blood pressure values), alongside self-report measures to balance subjective measurement biases and increase robustness of results. Also, the NACC UDS does not include treatment data (eg, therapy for PTSD). The role of treatment in mediating the relationship between PTSD and health factors among older adults is highly relevant and there is existing evidence to support improvements in physical and mental health symptoms with PTSD treatment.⁴⁵ Regarding TBI specifically, future research should further investigate the PTSD and TBI relationship among older adults with regard to standard TBI diagnostic criteria⁴³ to explore possible differences based on TBI severity and chronicity. Lastly, studies should also explore social determinants of health related to mental and physical health conditions (eg, marginalized identities, healthcare access, neighborhood environment⁴⁴) and their interaction with PTSD and comorbidities among older adults.

Conclusions

PTSD and its mental and physical health correlates in older adults are understudied. The present study revealed that a considerable number of mental health and physical health conditions were more prevalent among older adults with PTSD than those without, supporting theorized mechanisms underlying these comorbidities (eg, health risk factors and behaviors,¹⁷ HPA axis dysfunction,³⁷ biological aging processes^8,23). Additionally, there was a sizeable difference in TBI history among older adults with and without PTSD. These results suggest that assessment for PTSD among older adults with a TBI history is likely warranted and may benefit from inclusion in primary care based screening for early detection and connection to intervention,⁵ as would assessment of TBI history among older adults with PTSD. Future research should endeavor to elucidate the associations among PTSD, TBI, and other aspects of mental and physical health in older adults to inform clinical practice and interventions and reduce age-related challenges in this particularly vulnerable population.

Footnotes

Acknowledgments

The NACC database is funded by NIA/NIH Grant U24 AG072122. NACC data are contributed by the NIA-funded ADRCs: P30 AG062429 (PI James Brewer, MD, PhD), P30 AG066468 (PI Oscar Lopez, MD), P30 AG062421 (PI Bradley Hyman, MD, PhD), P30 AG066509 (PI Thomas Grabowski, MD), P30 AG066514 (PI Mary Sano, PhD), P30 AG066530 (PI Helena Chui, MD), P30 AG066507 (PI Marilyn Albert, PhD), P30 AG066444 (PI John Morris, MD), P30 AG066518 (PI Jeffrey Kaye, MD), P30 AG066512 (PI Thomas Wisniewski, MD), P30 AG066462 (PI Scott Small, MD), P30 AG072979 (PI David Wolk, MD), P30 AG072972 (PI Charles DeCarli, MD), P30 AG072976 (PI Andrew Saykin, PsyD), P30 AG072975 (PI David Bennett, MD), P30 AG072978 (PI Neil Kowall, MD), P30 AG072977 (PI Robert Vassar, PhD), P30 AG066519 (PI Frank LaFerla, PhD), P30 AG062677 (PI Ronald Petersen, MD, PhD), P30 AG079280 (PI Eric Reiman, MD), P30 AG062422 (PI Gil Rabinovici, MD), P30 AG066511 (PI Allan Levey, MD, PhD), P30 AG072946 (PI Linda Van Eldik, PhD), P30 AG062715 (PI Sanjay Asthana, MD, FRCP), P30 AG072973 (PI Russell Swerdlow, MD), P30 AG066506 (PI Todd Golde, MD, PhD), P30 AG066508 (PI Stephen Strittmatter, MD, PhD), P30 AG066515 (PI Victor Henderson, MD, MS), P30 AG072947 (PI Suzanne Craft, PhD), P30 AG072931 (PI Henry Paulson, MD, PhD), P30 AG066546 (PI Sudha Seshadri, MD), P20 AG068024 (PI Erik Roberson, MD, PhD), P20 AG068053 (PI Justin Miller, PhD), P20 AG068077 (PI Gary Rosenberg, MD), P20 AG068082 (PI Angela Jefferson, PhD), P30 AG072958 (PI Heather Whitson, MD), P30 AG072959 (PI James Leverenz, MD).

Author Contributions

MOP contributed to the conceptualization, methodology, writing of the original draft, and editing of the manuscript. CEJ contributed to the conceptualization, methodology, editing, and review of the manuscript. CEG contributed to the conceptualization, methodology, analyses, editing, and review of the manuscript. All authors approved the final version of the manuscript.

Declaration of Conflicting Interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: CEG receives royalties from Oxford University Press. MP and CEJ report no conflicts with any product mentioned or concept discussed in this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Malvina O. Pietrzykowski

Colleen E. Jackson

Charles E. Gaudet

Data Availability Statement

NACC data is available upon request from NACC at naccdata.org. The data have not been previously presented orally or by poster at scientific meetings.

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