Kathleen: I appreciate the introduction and thank you to everyone who has joined in for today's session and is planning to join in the Innovations in Geriatric Care virtual conference. I am going to jump right in and start talking about trauma-informed care. It is a very important topic. In order for us to provide effective healthcare services, we, as care providers, need to have a complete picture of that individual client's life situation both past and present. I am going to start off the presentation talking a little bit about long-term care guidelines because this is really a hot topic for us right now. I think trauma-informed care covers every single venue where occupational therapy practitioners would be working.
CMS and State Survey Guidance
F319 Trauma-Informed Care
The first mandate comes directly from CMS. This was issued and implemented in 2017, and it states specifically that a facility must ensure that residents who are trauma survivors receive culturally competent trauma-informed care. This is in accordance with professional standards of practice and accounts for resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization to the resident. This becomes really important if you are working in a long-term care type of community. In November 28th, 2019, Phase 3 of the Requirements of Participation for skilled nursing facilities will go into effect and a big part of that is trauma-informed care. This is something I am speaking on all over the country right now as individual communities are starting to prepare for that.
Regulatory Requirements
There are regulatory requirements.
- 483.40 Behavioral health services
- 483.40(a) Sufficient staff with competency skillset
- 483.40(a)(1) Caring for residents with mental and psychosocial disorders
- 483.40(b)(1) Attaining highest practicable mental and psychosocial well-being
The first is 483.40 behavioral health services. This states that that facility must provide the necessary behavioral healthcare and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of a client.
The next requirement, 483.40a, talks about sufficient staff with competency skill sets. Skilled nursing facilities are required to do staff competencies. This came through with Phase 2 of our requirements. Part of that staff competency is making sure that the nurses are able to approach someone with a trauma-informed lens and show empathy to that individual. This is an important piece no matter what area of practice you are in. Trauma-informed care is an empathic approach that all staff needs to use.
The third, 483.40a1, is caring for residents with mental and psychosocial disorders. A facility needs to make sure they have sufficient funding for anything that they need to do to implement this approach. They have to have the correct staff, and those staff members need to be competent.
Finally, the last requirement is attaining highest practicable mental and psychosocial well-being. As we hear more and more about trauma-informed care, and you will also see it on the State Survey guidelines, there is a limited view in some venues of what trauma-informed care is.
State Survey Guidelines
- “Mental and psychosocial adjustment difficulties” refer to problems residents have in adapting to changes in life’s circumstances
- Characterized by an overwhelming sense of loss of one’s capabilities; family and friends; ability to pursue activities and hobbies; possessions
- May have a sad or anxious mood or aggression
We are starting to hear a lot more about PTSD. However, trauma-informed care is so much more than just PTSD. The state survey guidelines come straight from the State Operations Manual. First, mental and psychosocial adjustment difficulties refer to problems that individuals have in adapting to changes in life circumstances. They go on to say that this could be related to an overwhelming sense of loss of one's capabilities, of their family or friends, the ability to continue to pursue activities and hobbies, and loss of one's possessions. It goes on to say that this might be characterized as a feeling of hopelessness or helplessness and that all learning and essentially all meaningful existence or living ceases to exist once somebody enters a nursing home, or the hospital, or some sort of post-acute type of community. I want to take a pause here for a moment. You might not be working in long-term care, but as occupational therapy practitioners, we know that meaningful experiences do not have to cease when you enter a nursing home. We can continue to do a lot of the things that we love and that are meaningful that bring us happiness. I just wanted to make that particular point.
Other manifestations include:
- Impaired verbal communication
- Social isolation
- Sleep pattern disturbance
- Spiritual distress
- Inability to control behavior and potential for violence
- Stereotyped response to any stressor
The state survey guidelines also talk about other manifestations. We could see these anywhere along the continuum. For example, if someone is a trauma survivor, we may see impaired verbal communication, a loss or a failure to have meaningful relationships, and sleep pattern disturbances. This may be disruptive changes in their sleeping or their resting patterns as it relates to their emotional needs. You may see this in home care or in an in-patient rehab facility. There can be disturbances in one's belief system or spiritual distress. They may display aggressive behavior, directed at self or at someone else. Again, this is important as many of us work in geriatrics. It is so important to tease out if it is a dementia-related behavior or something related to trauma. There can be stereotyped responses to stressors. It is the same characteristic response regardless of the stimulus, and I will explain in just a moment why that happens.
Background and Effects of Trauma on the Body
Overview
- Life trauma can lead to lifestyle practices that influence the development of chronic illness
- Trauma-informed care is an approach that recognizes trauma symptoms and acknowledges the role trauma plays in one’s life
(SAMHSA, 2015)
Before I get into the background, what we can do for treatment? One, we can provide an individual with opportunities for self-governance. We can give them the opportunity to be independent and to make choices. This can be an integral part of their care. We can orient them. It is very important for them to have a feeling of safety and to know what is coming next, what is expected of them, what is happening in the environment and to know when a change is occurring. I like to use the term person-directed care or person-directed living. Isn't that what we do as OT practitioners? We give that person an opportunity for autonomy. Have you ever know anyone, maybe it is yourself, someone else, or a loved one, who has had a life trauma that has impacted their health? I can almost guarantee that every single one of you is saying, "Yes, I know someone."
We need to recognize that trauma is incredibly pervasive. With more and more people have increased access to healthcare, it means that we, as healthcare practitioners, need to have a better understanding of behaviors that lead to chronic illness. Life trauma, as we will see in just a second, can lead to lifestyle practices that influence the development of chronic illness, and understanding past traumatic events in individual's lives can be key to us providing effective care. Trauma-informed care is an approach to engaging people with that history of life trauma, recognizing that trauma symptoms exist and we acknowledge the role the trauma has played in someone's life. We need to understand trauma in order to provide good care.
I am going to give you many examples as we go through this session. I gave this particular session to a group of administrators quite a while ago, and somebody contacted me after the presentation and said, "You know, that was so meaningful to me. Let me tell you a story." This administrator relayed this story about an individual in his community who had dementia and was a Holocaust survivor. In this community, there happened to be a CNA who was male from Germany. Administrators felt that pairing these two individuals together would be a great thing because they had a shared background as they were both German. However, that CNA came in and said, "Okay, Mrs. So-and-so. It is time to go to the shower." This individual began to demonstrate behaviors and was fearful. As you can guess, the "shower" was equivalent to going to the gas chamber. This facility thought they were doing a really good thing pairing these two together, but in reality, they re-traumatized this person because they brought up her background. Again, it is really important to keep in mind trauma to deliver appropriate care.
Adverse Childhood Events (ACE) Study
- Conducted from 1998 to 2010 at Kaiser Permanente Department of Preventative Medicine, in collaboration with the CDC
- 17,421 participants
- How do childhood events affect adult health?
(Felitti et al., 1998)
The Adverse Childhood Events study, or the ACE study, was conducted from 1998 to 2010 at Kaiser Permanente in collaboration with the CDC, the Centers for Disease Control and Prevention. There were 17,000 participants in this study, and they wanted to find out if childhood events affect adult health. This was initiated by Dr. Vincent Felitti who ran an obesity clinic with the Kaiser Permanente group. Over time, he noticed that he had about a 50%, five-year dropout rate in his obesity clinic. He dove deeper into those patient dropout records (about 2,000), and he did some interviews. He found that most of these individuals were born at a normal weight, had a history of abrupt weight gain, then they stabilized, and they lost weight. They were very successful at losing weight, but every one of them gained it back. He found that many of these individuals had been sexually abused or had sexual trauma as children. Because of that trauma, they turned to food or substance abuse to cope with it. He figured that there was some sort of correlation here, and there was.
- The more exposure a person had, the greater the risk for chronic disease, mental illness, violence, and being a victim of violence
- Twice as likely to be smokers
- Seven times more likely to be alcoholics
- Increase the risk of chronic bronchitis by 400%
- Increase the risk of suicide by 1,200%
(Felitti et al., 1998; Starecheski, 2015)
In this study, they found that there was definitely a link between abuse, rape, or some sort of issue or event that happened in childhood that provided a link between that and obesity, smoking, suicide, drug abuse, sexually transmitted infections, self-assessment of health, et cetera. These individuals were twice as likely to be smokers, and seven times more likely to be alcoholics. They had an increased risk of chronic bronchitis (400%), and risk of suicide increased by 1,200%. Obviously, there was an incredible impact just based on what happened to them as a child.
Physiological Response to Trauma
When you look at the physiological response to trauma, we see these stereotyped types of responses.
- Survival mode; state of constant hypervigilance
- Hypothalamic-pituitary-adrenal axis (HPA) stress response causes the release of cortisol
- Increased stress = increased HPA = impaired hippocampus neuron growth/atrophy
- Atrophy leads to decreased memory resources available to form an appropriate reaction to stress
(Sherin & Nemeroff, 2011)
Over time, an individual who lives in this environment with this constant threat of danger, they physiologically adapt and go into survival mode. And, their bodies remain in this state of constant hypervigilance with the hypothalamic-pituitary-adrenal axis, or the HPA causes this release of cortisol. As stress continues in this environment, the HPA continues to be activated. With that increased cortisol, there is impaired hippocampal neuron growth. As an aside, the hippocampus is the first thing to atrophy with dementia. With this atrophy, there are decreased memory resources that are available to form an appropriate reaction to stress.
- Decreased connectivity between the hippocampus and prefrontal cortex
- Amygdala treats perceived threats as real
- May appear overly defensive or angry
- Trauma is linked to CNS disorders, cardiovascular, respiratory, and sexual health problems
(Evans & Coccoma, 2014; Marcellus, 2014; Miehls & Applegate, 2014; Norman et al., 2006; Spitzer et al., 2009)
Then, there is a decreased connectivity between the hippocampus and the prefrontal cortex where the amygdala is. The amygdala tends to treat every threat as real even perceived or imaginary ones. This is why we see that characteristic response no matter what the scenario is. And so, this person who has gone through trauma may appear overly defensive or angry. They may demonstrate an exaggerated response for something, but it is not their fault. It is the amygdala and their impaired physiological response. What we start to see, because of that, is this link to CNS disorders, cardiovascular disorders, diabetes, respiratory, COPD, and all sorts of other issues that again, may or may not be under their conscious control.
Effects of Trauma on the Body
- Survivors may be more likely to smoke, drink alcohol, and abuse drugs
- Depression, anxiety, and emotional numbness
- Memory lapses, decreased ability to concentrate, and difficulty making decisions
- Inner feelings of shame, self-blame, being damaged, or that they are bad
(Haskell & Randall, 2009)
This person may be more likely to drink, smoke, have depression, anxiety, et cetera. They may have cognitive issues like memory lapses, an inability to concentrate, difficulty making decisions, and those sorts of things. You might think, "That's dementia or a cognitive issue," but it could be a response to trauma. On top of that, they may have feelings of shame, self-blame, and being damaged. Depending on what their trauma was, like rape, they may blame themselves. Other examples might include if they went to war or survived a natural disaster, but others did not, they may feel, "It should have been me and not them." They may deal with a lot of emotional issues on top of all of the physical issues.
Statistics: HHS
- 55% – 99% of women in substance use treatment and 85% – 95% of women in the public mental health system report a history of trauma
- Economic costs of untreated trauma-related alcohol and drug abuse alone were estimated at $161 billion in 2000
(Department of Health and Human Services, 2000)
These statistics are mind-blowing to me. Anywhere between 55 and 99% of women in substance abuse treatment and upwards to 95% of women in the public mental health system have reported a history of trauma. The latest statistic on the economic cost that I was able to locate was $161 billion in the year 2000, and the human cost obviously is incalculable. These statistics come from the Department of Health and Human Services. These are from the Centers for Disease Control.
- One in four children experiences some sort of maltreatment
- One in four women has experienced domestic violence
- One in five women and one in 71 men have experienced rape
- 12% of these women and 30% of these men were younger than 10 years old when they were raped
(CDC)
