Core findings from the United States
Holder (2016), who provided the most detailed analysis of service-connected disabilities among veterans in the United States, demonstrated that veterans of the Vietnam and Gulf War eras were more likely to report higher service-connected disability ratings. About 47% of Gulf War 2 and 45.6% of Vietnam-era veterans with a service-connected disability reported a rating of 50% or higher. These percentages are far beyond those of the Korean War and World War 2 or service in peacetime. It is no wonder, then, that most of the research on health and psychosocial issues of aging veterans with disabilities is generated from Vietnam and Gulf War data.
In a meta-analytic article that consisted of 11 studies of older veterans (aged 65 and above), Williamson et al. (2018) focused on mental health problems in elderly veterans. The meta-analyses found high prevalence rates of substance (5.7%) and
Concerns of aging veterans with disabilities 65 alcohol (5.4%) use disorders in older veterans. In a recent review. Cook and Sirni-ola (2018) presented a succinct review of the major studies on PTSD and aging. They covered several longitudinal investigations on the relationship between traumatic exposure and subsequent effects on health and functioning. They found signs that older adults with PTSD were at risk of not receiving timely and appropriate mental health treatment, indicating that targeted outreach could be helpful in increasing service use and improving care. They recommended that additional analysis was needed to explore the differences in functioning of young-old (65-74 years), middle-old (75-84 years), and old-old (85 years and older) subjects.
One of the recent cross-sectional studies, conducted by Goldberg et al. (2014), assessed functioning and PTSD in male Vietnam-era veteran twins. The study used the Vietnam Era Twin (VET) registry which consists of a national sample of twin pairs identified from military discharge records of males who served during the Vietnam era (1964-75). Findings indicated that PTSD was associated with diminished health functioning and increased disability in aging Vietnam-era veterans. The reductions in function were seen across a broad set of functional domains that included aspects of physical and mental health. Those who had both PTSD and frill combat exposure showed diminished mental health functioning in their aging as compared to those with low or non-exposure to combat.
The research is consistent with earlier studies (Kazis et al., 1999; Kessler et al., 1995; Magruder et al.. 2004). There is a debate among researchers whether PTSD is related to physical health. Boscarino (2004) and Schnurr, Spiro III. and Paris (2000) believe that PTSD has an impact on physical health, while others have emphasized behavioral factors as mediating the relationship between PTSD and physical health (Beckham et al., 1998; Schnurr & Spiro. 1999).
A recent study explored the association between PTSD and the prevalence of dementia in older veterans in an administrative database study of individuals seen within one regional division of the VA’s health care network (Qureshi et al., 2010). The study controlled for confounding factors in multivariate logistic regression. The group that had a significantly higher incidence and prevalence of dementia was veterans with PTSD who were decorated with the Purple Heart for being injured in military activity. However, it is unclear whether this is due to a common risk factor underlying PTSD and dementia or to PTSD being a risk factor for dementia. Tire researchers suggest that veterans with PTSD should be screened more closely for dementia.
Some evidence about the association between PTSD and dementia was published by Spielberg et al. (2015), who studied functional magnetic resonance imaging (MRI) data from 208 veterans of Operation Enduring Freedom. Operation Iraqi Freedom, and Operation New Dawn. Findings of this study demonstrated that PTSD re-experiencing symptoms were linked to weakened connectivity in a neural network involved in providing contextual information. A similar relationship was found in a separate network typically engaged in the gating of working memory, but only in veterans with mild traumatic brain injury' (mTBI). As in the earlier study, it is unclear whether dementia is presented before the trauma or is the consequence of trauma exposure itself.
An interesting recent review of the literature from 2010-16 (Wolf & Schnurr, 2016) searched for the link between PTSD, cardiovascular health conditions (e.g., metabolic syndrome, coronary artery' disease, stroke, and myocardial infarction), and accelerated cellular aging. PTSD was associated clinically with increased risk of cardio-metabolic health problems, offering evidence that behavioral (e.g., poor sleep, cigarette use, poor diet, insufficient exercise) and biological (e.g., autonomic reactivity, inflammation) factors served as mediators of these associations. It is possible that these behavioral and biological mechanisms lead to accelerated cellular aging, as regulated in the epigenome, which contributes to premature cardio-metabolic health decline. In terms of practice, the review recommends monitoring the changes of cardio-metabolic conditions among mid-life PTSD veterans.
Another concern with aging veterans with disabilities in the United States is their expressed social and economic problems. Wilmoth, London, and Heflin (2015) used data from the Survey of Income and Program Participation (SIPP) to examine whether veteran and disability statuses were jointly associated with poverty and material hardship among households that include an older adult. They found that disabled veteran households were not significantly different in terms of poverty, but exhibited the highest odds of home hardship, medical hardship, billpaying hardship, and food insufficiency. Tire findings suggest that current public income support programs for older veterans with disabilities, including those provided by the VA to disabled veterans, are not sufficient and need to be adjusted (Fulton et al., 2009).
Another concern is the utilization of health care services by mid-life and aging veterans with disabilities. Wu and Lewis (2015) studied utilization of health care services by 2,890 veterans with disabilities. Their primary core health problems were related to back and neck, arthritis, and cardiac secondary conditions. Additional common medical problems were bone fractures, joint injury, hypertension, and diabetes. Nearly 60% of the sample served in wartimes prior to 1975; 31.51% served in the Vietnam War (1964-75); 14.36% served in the period of 1955-64; 9.40% served in the Korean War; and 5% served in earlier wars (World War 2), implying that veterans in this sample were older on average. In terms of health care utilization, veterans aged 65 years and older were less likely to visit hospital emergency departments, and less likely to stay overnight at the hospital. The younger group may be more at risk for accidental injuries than middle-aged or older veterans are, while the oldest group may be more at risk for illnesses and therefore should stay overnight at the hospital.
Garcia et al. (2014) studied the attitudes of older and younger veterans toward mental health treatment and found that Vietnam War veterans (average age 62 ± 4.2 years) and veterans of the Gulf War (43 ± 6.8 years) were less likely to report negative treatment, while the younger veterans from Operation Enduring Freedom and Operation Iraqi Freedom (32 ± 8.2 years) were more likely to report negative treatment. However, older veterans' utilization rates were higher compared to younger veterans (Lee et al., 2015).
There is no doubt that marital status played an important role in health utilization; being married predicted a lower likelihood of staying overnight at the
Concerns of aging veterans with disabilities 67 hospital compared to veterans who were unmarried. The spouse and family members provided social support and tangible resources. Persons who were single -by virtue of divorce, widowhood, or never having been married - were without in-home care for recuperation after an outpatient procedure or a condition that required oversight. Therefore, they were more likely to remain overnight in the hospital to recover. These data are supported by Mistiy et al.’s earlier study (2001) demonstrating that veterans who were socially isolated were more likely to be rehospitalized compared to veterans who had a social support network.
