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As good as the geriatric services are at the VA, there are major gaps in the care continuum for older veterans. There is no assisted living or boarding home level of care, for example, and only certain veterans are eligible for admission to nursing homes paid for by the VA. After having received care at the VA for most of their adult lives, many veterans and their families are shocked to find that they are on their own to find residential placement.

As the rules of combat change to include women, that reality will slowly change. Care professionals and family need to take into account the clinical consequences of placing survivors of Military Sexual Trauma into an environment that is overwhelmingly male. In terms of residential arrangements, the older wards that house two to four veterans in a large room are giving way to smaller rooms with more privacy as facilities are re-modeled. In addition, the unbalanced gender environment does lead to challenging clinical situations.

Except for visitors, the world on a VA residential unit is divided up for the most part into male patients and female nursing staff. As more men enter the nursing field, this balance is changing, but sexual dynamics and frustrations can lead to conflicts and behaviors that require professional consultation. In large units with very little privacy, patients have no ability to have their need for intimacy emotional or sexual met in any practical way.

Given expanding lifespans, patients can live for more than a decade in residential settings with no access to sexual outlets of any type. Frustration and declining executive function may lead to acting out or inappropriate touching of staff or other residents. This kind of situation needs to be handled with tact, rather than accusations of sexual misconduct on the part of the veteran.

Unfortunately there is no good therapeutic solution to solve the dilemma of sexual frustration in these residential settings that I am aware of. In addition, geriatricians and psychiatrists are frequently consulted to medicate patients who would be much less likely to be having violent interactions with others if the environment was set up differently. Even if older units get remodeled, the basic structure still typically involves long, institutional hallways.

I have witnessed male residents with dementia pacing opposite sides of a corridor, getting more and more hostile toward each other as they pass. If they both happen to get stuck at the end of the hallway, or one drifts across into the path of the other, fights sometimes occur. Institutional design can also create clinical dilemmas. Budgets frequently do not allow for needed staff let alone new or more effectively designed units. Alcohol abuse is much more prevalent in veterans later admitted to nursing homes compared to residents of community nursing homes.

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In fact, a substance abuse history increases the risk that a veteran will need nursing home placement. Per Lemke and Schaefer , 1. Statistically, veteran nursing home residents with substance abuse histories tend to be younger, more likely to smoke, more mobile, to be verbally disruptive, and to have serious mental illness including PTSD than those without substance abuse histories. The biggest difference in working with veterans compared to patients in the community is their combat exposure and high risk for PTSD.

Post-Traumatic Stress Disorder is also an issue for elders in the community, but tends to be less obvious and more likely to be related to having experienced childhood abuse or domestic violence. Even though childhood abuse survivors were also potentially put into emotional double binds by their experiences, there is a difference in the late life issues of having survived violence vs. Post-Traumatic Stress Disorder is a tricky thing.

Combat exposure definitely increases the risk of developing PTSD, but it sometimes does not emerge until late life. The emergence of PTSD symptoms in late life after retirement age has been noted to correlate with the onset of dementia Johnston, These symptom delays may be biological, as the dementing brain seems to go backwards in time through old experiences.

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Some of it may be Ericksonian, as retired or aging veterans review their lives. It tends to happen in veterans who, although they had exposure to high stress combat, functioned well after they returned from their military service and into middle age.

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LOSS tends to come on with a major life event e. For some, increasing physical disability recalls experiences of being wounded or helpless—the old terrors return. Providing comfort measures for the physical symptoms may help put those terrors back to rest. For example, a long time patient, Mr.

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R, who as a young soldier had been hospitalized for 18 months after a near-fatal chest wound, began having nightmares and flashbacks of his buddy bleeding to death in his arms on a battlefield the same battle where he himself was also critically wounded. The emergence of these troubling symptoms correlated with his increasing physical pain and shortness of breath as his body aged and he developed kyphosis.

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