Elsevier

General Hospital Psychiatry

Volume 33, Issue 2, March–April 2011, Pages 177-184
General Hospital Psychiatry

The association of traumatic experiences and posttraumatic stress disorder with health care utilization in the elderly — a German population based study

https://doi.org/10.1016/j.genhosppsych.2010.12.006Get rights and content

Abstract

Objective

Traumatic experiences (TE) and posttraumatic stress disorder (PTSD) are related to impaired mental and physical health and to increased health care utilization (HCU). However, general population studies simultaneously investigating the association of TE and PTSD with HCU in the elderly are lacking to date.

Methods

A representative sample of 1456 people aged 60–85 years from the German general population was examined using self-rating instruments for TE, PTSD, HCU and physical health (PH).

Results

In regression analyses including age and gender, TE are significantly associated with increased probability of visits to specialists and to mental health professionals, and of hospitalization, but not with the frequency of HCU. Current PTSD is significantly associated with increased probability of visits to mental health professionals and of hospitalization, and with increased frequency of general practitioner visits, of specialist visits, and of visits to mental health professionals. In two mediation models, the relationships between TE and PTSD, respectively, with HCU were weakened but remained significant after including PTSD and physical morbidity, respectively.

Conclusion

These results indicate that both trauma and PTSD are positively associated to some indicators of HCU. Posttraumatic stress disorder has a weak mediating role in the association of TE and HCU. Physical health has a weak mediating role in the association of PTSD and HCU.

Introduction

A significant body of literature has examined the impact of both traumatic experiences and Posttraumatic Stress Disorder (PTSD) on mental and physical health as well as on health care utilization. Traumatic experiences and PTSD are related to impaired mental and physical health as well as to increased health care utilization. However, general population studies simultaneously investigating traumatic experiences and PTSD and their association with health care utilization are lacking to date. Most of the existing studies are based on selected samples. Nevertheless, previous studies in combat and peacekeeping veterans [1], [2], [3], [4], [5]; in victims of rape, physical, or sexual abuse [6]; in survivors of natural disasters [7] and in primary care attendees [8], [9], [10] documented the association with increased health care utilization. Some of these studies exclusively investigate the association of traumatic exposure with increased health care utilization (e.g., [1], [6]), and other studies focus on the association of PTSD with increased health care utilization (e.g., [2], [3], [10]). Generally, studies about the association of traumatic exposure or PTSD with health care utilization found positive associations. In detail, the findings differ, which is largely attributable to different health care systems in the countries of the studies, different samples and different assessment methods. However, the study by Magruder and colleagues [11] in primary care attending veterans revealed no differences in use of primary care, urgent care and inpatient care in patients with PTSD compared to those without PTSD.

In recent years, the mechanisms of the interaction of traumatic exposure, PTSD, and health care utilization have been under debate. On the one hand, PTSD as the most common psychological consequence of traumatic experiences is discussed as a mediator of the association of traumatic exposure and increased health care utilization, but findings are inconclusive. Rosenberg et al. (2000) found traumatic exposure, but not PTSD, to be related to increased health care utilization [12]. In contrast, Ford and colleagues (2004) showed that PTSD has a mediating role in the association of traumatic exposure and health care utilization. On the other hand, the role of impaired physical health, as a common long-term consequence of PTSD, is discussed as a possible mediator between PTSD and increased health care utilization. Using structural equation models, two research groups proved that physical morbidity has a mediating role for increased health care utilization in subjects with PTSD [13].

In European countries, where civilians were also broadly involved in the sequels of World War II, a substantial number of the elderly population underwent war-related traumatic stress. In a German population-based study, the frequency of war-related traumatic experiences increased from 19.2% in the group aged 60–64 years up to 59.7% in the age group 75 years and above. Compared to the younger age groups, the German elderly carry a dramatically increased traumatic burden, mainly contributed by the effects of World War II [14], [15]. In its consequence, the German elderly are more often affected by posttraumatic symptomatology. The prevalence of PTSD increases from 1.31% in the youngest age group (14–29 years) up to 3.44% in the age group 60 years and above [15]. Because of the historical background and the findings about its long-term consequences in the German elderly population, it is of special interest to investigate the association of traumatic exposure and PTSD on health care utilization of the elderly and the possible underlying mechanisms.

To our knowledge, this is the first population-based study in the elderly which investigates the following:

  • 1.

    the association of lifetime history of traumatic exposure and current PTSD with health care utilization,

  • 2.

    the mediating role of PTSD in the association of traumatic exposure and increased health care utilization and

  • 3.

    the mediating role of physical morbidity in the association of PTSD with increased health care utilization.

Section snippets

Subjects

A representative sample of the German general population was selected with the assistance of a demographic consulting company (USUMA, Berlin, Germany). The area of Germany was separated into 258 sample areas representing the different regions of the country. Households of the respective area and members of these households fulfilling the inclusion criteria (age at or above 14 years, able to read and understand the German language) were selected randomly. The sample was aimed to be

Trauma exposure and PTSD

The study sample comprised 1456 people aged 60–85 years from the German general population. Based on the results of the trauma list and the PTDS, participants were assigned to one of the following groups: no trauma exposure (N=966/66.3%), trauma exposure but no current PTSD (N=423/29.1%) and current PTSD (N=67/4.6%). Detailed information about the traumatic experiences is reported elsewhere [29]. Table 1 shows the sociodemographic characteristics of these three subsamples. The subsamples

Discussion

The present study examines the association of traumatic experiences and PTSD with health care utilization in old age. To our knowledge, this is the first representative population-based study on this topic in this age group. Hence, the experience of a trauma was not a selection criterion of the sampling procedure.

Nowadays, it seems consensual that traumatic experiences and PTSD are associated with increased health care utilization. Nevertheless, findings of the various studies about this topic

Acknowledgments

The study was supported by a grant from the Medical Faculty of the University of Leipzig to Heide Glaesmer. There are no conflicts of interest.

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