Best Practices in Nursing Care for Older Adults with PTSD
From the John A. Hartford Institute on Geriatric Nursing www.hartfordign.org
Issue Number 19, 2004
Series Editor: Marie Boltz, APRN, MSN, GNP
Horowitz’s Impact of Event Scale
An Assessment of Post Traumatic Stress in Older Adults
By: Joan Marren, MEd, RN, Chief Operating Officer, VNSNY and Steven Christianson, DO, MM, Medical Director, VNS CHOICE and VNSNY Home Care
WHY: Like others with Post Traumatic Stress Disorder (PTSD), older adults respond to trauma with symptoms of re-experiencing, emotional numbing, behavioral avoidance, and increased physiological arousal. Because of age-related changes and associated disease processes, stress reaction in older adults may lead to a deterioration of function and a worsening of existing conditions. Therefore, older adults should be considered a high risk group following a disaster. Several factors in adapting to disaster have been recognized as important in the older adult: an increased sense of insecurity and vulnerability; a loss of sense of control and predictability; and a need to reaffirm familiar relationships, attachments and routines and to remain independent. The impact of disaster on the elderly can be magnified by chronic Illness and medication, sensory limitations, mobility impairment, and literacy which place the older adult in the special needs population after a disaster. For all of these reasons it is important to evaluate an older adult’s response to a disaster to detect those who are in danger of decompensating.
BEST TOOL: A short easily administered self-report questionnaire of 15 questions, the Horwitz Impact of Event Scale (IES), developed by Mardi Horowitz, is an appropriate instrument to measure the subjective response to stress in the senior population, especially in the response sets of intrusion (intrusive thoughts, nightmares, intrusive feelings and imagery) and avoidance (numbing of responsiveness, avoidance of feelings, situations, and ideas), as well as a total subjective stress score. The IES is recognized as one of the earliest self-report tools developed to assess post traumatic stress. IES is the acronym for the test assessment purpose:
I– Impact
E – of Event
S – Scale
TARGET POPULATION: The population assessed by IES are adults exposed to any specific life event stress. It can be used for both healthy and frail elderly, and can be used for repeated measurements over time to monitor progress.
VALIDITY/RELIABILITY: The questionnaire has been used to discriminate a variety of traumatized groups from non-traumatized groups in general population studies, and the sub scales of avoidance and intrusion show good internal consistency. While the subscales are related they measure different dimensions of stress response. Blacks have been shown to score higher than whites on the IES in general population studies, an effect that diminished with increasing relative violence, and this should be taken into account during interpretation
STRENGTHS AND LIMITATIONS: The main strengths of this instrument are that it is short easily administered and scored, and can be used repeatedly to assess progress. It is limited by remaining a screening not comprehensive test, has a non-clinical focus, and is best used for recent not remote traumatic events.
IES: An Assessment of Post Traumatic Stress in Older Adults
THE INSTRUMENT
Question:
- I thought about it when I didn’t mean to.
Response:
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - I avoided letting myself get upset when I thought about it or was reminded about it.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3)
Often (Score 5) - I tried to remove it from memory
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - I had trouble falling asleep or staying asleep because of pictures or thoughts about it that came to my mind.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - I had waves of strong feelings about it.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - I had dreams about it.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - I stayed away from reminders about it.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - I felt as if it hadn’t happen or was unreal.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - I tried not to talk about it.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - Pictures about it popped into my mind.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - Other things kept making me think about it.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - I was aware that I still had a lot of feelings about it, but I didn’t deal with them.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - I tried not to think about it.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - Any reminder brought back feelings about it.
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5) - My feeling about it were kind of numb
Not at all (Score 0)
Rarely (Score 1)
Sometimes (Score 3
Often (Score 5)
INTERPETATION:
Total Stress Score-0-8 Subclinical range
9-25 Mild Range
26-43 Moderate Range
44+ Severe Range
SCORING:
Intrusive sub-scale
(#1, 4, 5, 6, 10, 11, 14) = 0 to 35 points possible
Avoidance sub-scale
(#2, 3, 7, 8, 9, 12, 13, 15) = 0 to 40 points possible
Total Stress Score = Avoidance Sub-scale + Intrusive Sub-scale = 0-75 points possible
MORE ON THE TOPIC:
Horowitz, M.J., Wilner, M., & Alverez, W. (1979). Impact of Events Scale: A measure of subjective stress. Psychosomatic Medicine 41, 209-218.
Horowitz, M.J., (2003). Treatment of stress response syndromes. Washington, DC: American Psychiatric Press.
Horowitz, M.J., Stress response syndrome (4th Ed.). (2002). Northvale, NJ: Aronson.
National Center for Post Traumatic Stress Disorder www.ncptsd.va.gov
CDC – Helping People Cope with a Traumatic Event, http://www.cdc.gov/masstrauma/factsheets/professionals/coping_with_trauma.htm
Guide to Emergency Preparedness for Seniors and People with Disabilities, NYC Department for the Aging