Veterans Aging

Abstract

More than 20 million American veterans are alive today. Their median age is 64 years (National Center for Veterans Analysis and Statistics, 2015); most are men (National Center for Veterans Analysis and Statistics, 2014). The largest surviving cohort of veterans served in the Vietnam War (7.5 million) and is rapidly entering old age. Veterans of the Korean War (2.4 million) and World War II (WWII; 2.0 million) are experiencing late old age. Veterans of the more recent Gulf War, Afghanistan War, and Iraq War are also aging. More than half of Gulf War veterans are aged 45 and older (16% are between 55 and 85 years; U.S. Department of Veterans Affairs, 2011) and 8% of people deployed in the Afghanistan and Iraq wars were born before 1960 ( Dursa, Reinhard, Barth, & Schneiderman, 2014 ). Although joining the military is a critical turning point of early adulthood, likely to affect the way people age, wartime experiences remain a “hidden” variable, seldom measured or considered in studies of aging ( Settersten & Patterson, 2007 ). In an effort to further a scholarly, multidisciplinary dialogue about the lives of diverse groups of aging veterans and society’s accommodations to multiple generations of veterans as they move through middle and older adulthood, The Gerontologist invited authors to contribute novel conceptual manuscripts, empirical research articles, and innovative review articles that address this growing population. We welcomed articles that were conceptually based, methodologically sophisticated, and oriented toward policy and practice. Quantitative, qualitative, and mixed methods approaches were encouraged from multiple disciplines. The 15 articles in this Special Issue highlight the salient role that serving in the military has for veterans and their families. The articles teach us that wartime experiences are complex and that many hidden variables associated with wartime experiences affect the aging process. The well-developed conceptual model for examining the long-term consequences of military service for aging veterans proposed by Spiro, Settersten, and Aldwin (2016) situates military experience within a person’s life trajectory and sociohistorical context. Drawing on a life-span perspective, their model rests on five principles: (i) the effects of military service are life long, (ii) the effects of service are multidimensional, affecting multiple domains of life, (iii) military service leads to both gains and losses, (iv) the effects of service are experienced within a matrix of social relationships that can protect or create risk for veterans, and (v) the effects of military service occur within a sociohistorical context. This model alters the nature of questions that researchers should ask about military experience, expands outcomes from predominantly negative consequences to the full continuum of negative, null, and positive effects, and calls for more sophisticated measures of military service. In a companion piece, Davison and colleagues (2016) suggest that in later life, many combat veterans confront and rework their wartime memories in an effort to find meaning and build coherence. Through reminiscence, life review, and wrestling with issues such as integrity versus despair, aging veterans intentionally reengage with experiences they avoided or managed successfully earlier in life, perhaps without resolution or integration. Davison and colleagues suggest that the process of later-adulthood trauma reengagement can lead positively to personal growth or negatively to increased symptomatology. They suggest preventive interventions that can enhance positive outcomes for veterans who reengage with their wartime memories in later life. Using data from WWII and Korean War veterans who participated in the VA Normative Aging Study, Kang, Aldwin, Choun, and Spiro (2016) tested a life-span model of combat exposure on posttraumatic stress disorder (PTSD) in later life. They examined prewar (childhood trauma, family cohesion, and age at entry), warzone (combat exposure, appraisals of military experience, and unit cohesion), and postwar factors (homecoming experience and other stressful life events) and found that cumulative advantage and disadvantage pathways were not independent. A supportive childhood family environment can have lifelong protective effects, whereas a conflict-ridden family environment can set up lifelong patterns of pessimistic appraisals. Moreover, unit cohesion and positive appraisals of military service had protective effects on PTSD whereas negative appraisals of military service and negative homecoming experiences increased vulnerability to PTSD. The wars in which the current generation of aging veterans fought—WWII, Korean War, and Vietnam War—were very different from one another. WWII was the defining event of the 20th century. High manpower needs of WWII drew 16 million men—about half the eligible population of men—from all social strata. Serving in the military was the normative experience for men born in the 1920s. When veterans of WWII came home, they were welcomed as heroes. The GI bill facilitated economic and educational gains. The proportion of the population serving in the military declined following the WWII, and the characteristics of those serving changed dramatically. Similarly, political and public sentiments surrounding the Vietnam War were very different than those regarding WWII. Over time, the military has become more diverse in terms of gender, race, and ethnicity but less diverse in terms of socioeconomic status. Black (2016) reports on qualitative interviews that addressed issues of racism and social change with five veterans. She explores the experiences of war and suffering among African American veterans who served in WWII, Korean War, and Vietnam War. Black identifies three central themes: (i) expectations related to war, (ii) suffering as an African American, and (iii) perception of present identity. Each man interviewed was honed by the sum of his experiences, including those of combat, racism, and postwar opportunities and obstacles. Black’s work reminds us of the importance of historical context, demonstrating how different the three wars were for the men who served. Studies that take advantage of large VA populations and the rich data collected from and about them can teach us much about the aging process. Wojtusiak, Levy, Williams, and Alemi (2016) analyzed Electronic Health Record data from 5,595 residents of Veterans Affairs’ Community Living Centers (CLC) within the VA Informatics and Computing Infrastructure. Data included diagnoses from 7,106 inpatient records, 21,318 functional status evaluations, and 69,140 inpatient diagnoses. Analyses identified seven patterns of recovery and loss in functional ability and found that functional decline and recovery can be predicted with relatively high accuracy following hospitalization of nursing home residents. A distinct advantage of the study was access to a wealth of data that included functional status measures collected within 2 weeks prior to hospitalization. Similarly, Levy, Zargoush, and colleagues (2016) analyzed activities of daily living (ADL) data extracted from standard minimum data set assessments from 296,051 residents in Veteran Affairs nursing homes. They identified 25 combinations of ADL deficits that described the experiences of 84.3% of residents and used a network model to describe transitions among these 25 combinations. Levy, Zargoush, and colleagues found that the majority of residents followed four pathways of loss of function, the most likely sequence being bathing, grooming, walking, dressing, toileting, bowel continence, urinary continence, transferring, and feeding. Knowing that recovery of deficits follows a predictable path enables effective interventions to be developed. In a study contrasting hospitalization rates for people living in VA Medical Foster Home (MFH) program which provides a community-based living arrangement for adults who cannot live independently due to physical or mental disabilities and those of VA CLC nursing homes, Levy, Alemi, and colleagues (2016) found that compared with matched CLC cases, MFH residents were less likely to be hospitalized for adverse care events, anxiety disorders, mood disorders, skin infections, pressure ulcers, and bacterial infections. MFH and CLC did not differ in rates of urinary tract infections, pneumonia, septicemia, suicide, falls, other injuries, cognitive impairments, or adverse drug reactions. These findings suggest that noninstitutional care by a nonfamily caregiver does not necessarily increase hospitalization rates for common medical conditions, suggesting that quality of care does not have to be compromised for quality of life. In a similar vein, studies that capitalize on prevalent health conditions experienced by veterans can teach us much. Green, Fairchild, Kinoshita, Noda, and Yesavage (2016) , noting the association between cognitive decline, PTSD, and metabolic syndrome (MetS), as well as the high prevalence of PTSD and MetS in older veterans, hypothesized that co-occurring PTSD and MetS would be associated with worse cognitive performance than that seen in either illness alone. Green and colleagues found that veterans with MetS demonstrated poorer performance on tasks of executive function and immediate verbal memory, regardless of PTSD status. There was an interaction between MetS and PTSD on delayed verbal memory, suggesting that the negative impact of MetS on verbal memory was only significant for veterans who did not have PTSD. Although studies based solely on older veterans offer many benefits for increasing our understanding of the aging process, they also have limitations. Findings from studies including only residents of VA facilities may reflect the idiosyncratic nature of treatment, nursing care, and assessment within one large health care system; hence generalization of knowledge is limited. Yet, when findings such as those reported by Levy, Alemi, and colleagues (2016) from veteran studies are similar to those from nonveteran studies, we have greater confidence in the generalizability of their findings. Studies that directly contrast the experiences of veterans and nonveterans complement those that include only veterans. Drawing from two waves of the National Comorbidity Survey, Sachs-Ericsson, Joiner, Cougle, Stanley, and Sheffler (2016) examined how exposure to combat in early adulthood contributes to the development of PTSD with age. Hypothesizing that prior exposure to trauma sensitizes people to respond more intensely to subsequent stressors, Sachs-Ericsson examined whether veterans were more reactive to stressors of aging than nonveterans. Controlling for baseline demographics, number of psychiatric diagnoses, and life time PTSD, they found that combat predicted PTSD but that recent life stressors were also associated with PTSD. Interestingly, the effect of combat on PTSD was significant at high levels but not at low levels of recent stress. Using the 2013 HRS Veterans Mail Survey linked to the Health and Retirement Survey (HRS), Taylor, Ureña, and Kail (2016) examined military service experiences and health trajectories over a decade among veteran men. Although they found a connection between combat and later health, it was driven primarily by hazardous or traumatic exposures. Consistent with the model by Spiro and colleagues (2016) , these findings suggest that service-related exposures are varied and complex and have differential connections to late-life health. Such findings highlight the importance of developing measures of military experiences that adequately assess the varied experiences of soldiers. Finally, using data from the National Longitudinal Survey, Hardy and Reyes (2016) examined the health advantages of selection into military service and health disadvantages associated with military service by comparing later-life mortality rates for veterans and nonveterans as well as among veterans based on their cohort of entry into civilian life. They found that when considering the full range of birth cohorts, there were no differences in mortality rates by veteran status. But, veterans who were discharged from the military at older ages had a mortality advantage relative to veterans discharged at younger years. Results support a selection hypothesis whereby positive health selection provides a mortality advantage initially that weakens over time. While the studies described thus far examine the experiences of men, 400,000 living women veterans aged 65 and older served in WWII, Korean War, and Vietnam War (National Center for Veterans Analysis and Statistics, 2014). Padula and colleagues (2016) using data from the Women’s Health Initiative (WHI) compared the cognitive functioning of 7,330 women veteran and nonveterans. Compared with nonveterans, veteran women were older, were more likely to be Caucasian and unmarried, and have higher rates of socioeconomic status. Results on unadjusted baseline analyses suggest that Modified Mini-Mental State Examination scores were similar for veterans and nonveterans. Longitudinal analyses, adjusted for age, education, ethnicity, and WHI trial assignment, revealed difference in the rate of cognitive decline between groups over time, such that scores decreased more in veterans than in nonveterans. The relative difference was more pronounced among veterans who were older, had higher socioeconomic status, and had greater baseline prevalence of cardiovascular risk factors. Veteran status was associated with higher prevalence of protective factors that may have helped initially preserve cognitive functioning. Findings ultimately revealed more pronounced cognitive decline among veterans than among nonveterans, likely suggesting the presence of more advanced underlying neuropathology. While this is the only study in the Special Issue to address the experiences of aging women veterans, The Gerontologist published a companion Supplemental Issue this month entitled “Women Veterans in the Women’s Health Initiative.” The three Practice Concepts pieces translate interventions designed to better the lives of family caregivers that were developed among non-VA populations to VA clientele. They directly address questions about whether programs developed elsewhere can be implemented in the VA and examine the extent to which findings are generalizable. Karel, Teri, McConnell, Visnic, and Karlin (2016) adapted the evidence-based Staff Training in Assisted Living Residences (STAR) program into an interdisciplinary clinical intervention for veterans with dementia in VA CLC settings, maintaining the core components of the original program. Findings support the strength of mental health professional and nursing collaboration for implementing a new behavioral care model. Nichols, Martindale-Adams, Burns, Zuber, and Graney (2016) describe the process by which a behavioral intervention for caregivers of persons with dementia—Resources for Enhancing Alzheimer’s Caregivers Health (REACH)—was translated, expanded, and implemented in a VA setting. They detail the six phases (exploration and adoption, program installation, initial implementation, full operation, innovation, and sustainability) required to adapt the intervention to VA clinicians and a VA population who were seriously wounded in Iraq and Afghanistan Wars. The process of moving from REACH to REACH VA yielded a reduction in intervention sessions from twelve to four. Telephone support groups became optional, complementary, or standalone, and the mode of delivery changed from face to face to telephone or telehealth. Evaluation revealed that these changes did not impact outcomes. Finally, Griffiths, Whitney, Kovaleva, and Hepburn (2016) developed an internet-delivered version of the Savvy Caregiver program that retained a group format but was accessible to caregivers in their homes. The process of transforming an in-person program—the Savvy Caregiver—into a synchronous and asynchronous internet-based program (Tele-Savvy) is described in detail, and preliminary outcomes of initial implementation of the program through a Department of VA-supported clinical demonstration project are presented. First, the Savvy Caregiver curriculum was deconstructed, and the components that benefitted most from a group context were identified. Then, the face-to-face program was translated into an internet-delivered distance program (Tele-Savvy). Results of initial implementation indicate that Tele-Savvy was successful in staying true to the format, content, learning targets, and process of the original program. Together these articles set the stage for the next generation of research about how military experiences affect the aging process. They teach us that the effects of service vary by era and by conflict and warn us that findings about today’s aging veterans may not apply to future cohorts of veterans. The importance of carefully measuring military exposures is a theme running through many of the articles. For the next generation of studies, it will not suffice to dichotomize military experience as present or absent. Instead, we need to systematically collect information about where and for how long people served, whether they participated in active combat, and what stressors they were exposed to. Our understanding about how military experiences affect the aging process is tempered, as many of these articles indicate, because selection effects are particularly problematic across the literature on veterans. Those veterans most affected by war and combat die before being interviewed ( Settersten, 2006 ). In addition, because military selection and deployment are predicated on robust good health, people who serve in the military will be different from those who do not serve and those with advantaged socioeconomic backgrounds are less likely to witness heavy combat or environmental exposures. As such, it will be important that future studies on the health and well-being of aging veterans include comparisons with nonveteran populations.

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