Caring for war veterans--victims or heroes? Undiagnosed and untreated symptoms of post-traumatic stress disorder affect many World War 11 veterans at Auckland's Ranfurly Veteran Centre. Nurses and caregivers need education to care for veterans appropriately.

RANFURLY VETERANS' Centre in central Auckland is home to 142 war veterans (and/or their spouses). It is a sanctuary to those who have served their country, providing hospital, rest-home and secure unit care.

Ranfurly was founded in 1903 by the then Governor of the Colony of New Zealand, the Earl of Ranfurly, as a national memorial to honour the servicemen who died in the South African war. The honours' board in the foyer of Ranfurly bears the names of 272 fallen soldiers. The centre has continued to care for those who served in war for over 100 years.

During the Second World War, some 155,000 New Zealanders served in the armed forces. Now 58 years on, with all World War II veterans 75 years or older, the affects of the war have led to a complex range of physical, cognitive and emotional symptoms.

Certain common behaviours manifest themselves among the returned service men and women living at Ranfurly. Some are attributable to their participation in military life and their experience of the atrocities of war. I believe a full military history should be obtained as part of the nursing and medical assessment of residents, to ascertain potential and real problems that can be dealt with. The problems and behaviour of age-related pathology vs war-related causes need to be sifted. Skilled and sensitive staff, with knowledge of war, military life and the special needs of the older adult, will he able to elicit this information and plan appropriate care.

Consideration needs to be given to the type of food soldiers ate during wartime and the long-term physical and emotional effects of malnutrition many suffered. At Ranfurly, residents often hide food and it is not unusual to find one or two kilos of fruit or bread hidden in a veteran's room, sometimes on a daily basis. Food is usually taken from the dining room to "have later" but is rarely eaten. The centre provides three substantial meals a day as well as morning and afternoon tea and supper, but hoarding and stealing from other veterans' rooms is not uncommon. Residents want meals that are basic and plain--no rice, "foreign food" or fancy foods are served. Veterans are outside the dining room at least 30 to 45 minutes prior to a meal, and then it's in, eat and leave--no socialising here.

Meals for our 82 rest-home veterans are served in a large communal dining room, with table service now replacing the former army style of queuing for service. A recent effort to make this area more attractive with potplants was not a success. A table setting at home and in the services would be very plain, and would include condiments and a cup of tea along with the meal and no "fancy decorations". While food is obviously a daily highlight, it is not a social highlight but a function that is undertaken as a necessity of life and not as a social event.

Alcohol was readily available during the war, even if made from potatoes or anything else that could be fermented. It was a relief to the pain and suffering, and anaesthetised the pain and agony of seeing broken and battered bodies day after day. Of ten there was nothing else to do but work, sleep and drink alcohol. Not surprisingly, drinking patterns developed. Leave from the frontlines became an opportunity for soldiers to drink heavily and forget what they had seen and done.

Alcohol is also a co-morbidity of posttraumatic stress disorder (PTSD). Alcohol used to be a feature of any social event at Ranfurly and was served in copious amounts. Now it is served at social functions only, and in controlled amounts. However, alcohol is not seen as a social activity when part of an evening meal at these special functions, but drunk as quickly as possible so more can be had. As one veteran said to me: "I didn't come to socialize--I just eat, drink and go." The number of residents with drinking problems is high--about one in five--but most problems are managed successfully.

Smoking is a never-ending problem, not just because of the fire risk, but also for the obvious health risks. Cigarettes were given to service people freely as a "comfort" item and were also used as a bartering/bribing tool for food or other comforts. The number of veterans who smoke is high and it is difficult at this stage to change entrenched habits. Smoking has caused or exacerbated severe respiratory problems and does not help those who have respiratory complications from serving in the blinding dust storms of middle eastern deserts.

Close relationships are not often formed at Ranfurly. Whether this is due to residents feeling their personal space is being invaded as a result of their having PTSD or the fact that close friends made during the war often died, is unknown. However, one piece of literature describing the "Rules of War" may give some clue:

Rule 1: DO NOT make friends (because of Rule 2)

Rule 2: Young men die and

Rule 3: Doctors and nurses cannot change Rule 2 (1)

In the 1996 census, six percent of males over 65 in the Auckland area had never married, while at Ranfurly, 17 percent had never married. Two percent of males over 65 were stated as separated, whereas at Ranfurly the figure was nine percent. (2) It is not uncommon to have a veteran with no family or one who left his family immediately after the war. One veteran declared himself "single" but in fact had six children who managed to track him down. Many veterans returning from war "went bush" and lead a lonely existence, usually due to PTSD--probably unrecognised at the time. (3) At Ranfurly, often families will appear after a 20-30 year gap to seek reconciliation, sympathetic now that "Dad" is an old man.

PTSD is defined as "the development of characteristic symptoms following a psychologically traumatic event that produces tear, helplessness or horror". (4) War is a prime example of this.

After the Vietnam War, many studies were undertaken into PTSD but few have ever been done on its effects on World War 11 veterans. One study of World War 11 veterans in Australia and New Zealand showed 45 percent had PTSD. (4)

PTSD encompasses numerous signs and symptoms, with co-morbities of depression, alcohol abuse, panic and phobic disorders and generalised anxiety disorders. As far back as the American Civil War, words like "shell shock", "soldier's heart" and "war neurosis" are mentioned, (3) but it was not until 1980 that the American Psychiatric Association identified the PTSD diagnosis. (4)

PTSD falls into three broad areas:

Re-experiencing symptoms: The person may feel he is re-living the events/thoughts/ dreams/nightmares. Sometimes he may act out the dream while still asleep, or he may have dissociative flashbacks, ie feeling he is reliving the event. Residents may experience anxiety when exposed to loud noises, confinement, or the loss of close persons or things connected to these traumatic events. They may become upset when exposed to war movies or war songs.

Avoidance: The person may avoid places, people or events that are reminders of the trauma (eg Anzac Day). Consider what a shower may mean to a Jewish person whose family was in a concentration camp or to the soldier who liberated the survivors of these camps, or what a wire fence will mean to a prisoner of war. The person can become "numb" to their surroundings and not experience normal everyday emotions, even towards those close to them.

Arousal symptoms: Some veterans are chronically irritable or angry (eg prone to angry outbursts with themselves, others around them and in the world in general), cannot sleep and have trouble concentrating. These people often see danger everywhere and, as a consequence, feel constantly on guard. Some become physically aggressive and violent and often feel unable to control their anger. (4)

It is obvious many of our veterans experience PTSD, undiagnosed and untreated. Case studies and reports indicate this syndrome is a lifelong disorder, still present 58 years after the cessation of hostilities. (4)

Three years ago, I attended a workshop at the National Centre for War Related PTSD (the only centre in Australasia treating elderly war veterans) in Melbourne. I returned to Ranfurly enthusiastic to follow this issue further. With the help of our occupational therapist, we conducted our own study to ascertain the degree of PTSD within our facility. Veterans were initially pre-screened (with their permission) to determine whether they met the PTSD criteria requiring further investigation. Direct questioning was pursued sensitively, because of the possibility of unearthing distressing recollections. Those questioned, however, were willing to participate--"as it might help someone else".

Those with confirmed dementia, non-veteran personnel (eg spouses) and those with a history of inactive service (eg home guard) were not included in the study.

The PTSD screening tool relies on symptoms from the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association 1980, minus symptoms normally experienced by the elderly). Ten questions were asked:

1) Are you bothered with unwanted memories of war?

2) Is it hard for you to feel close to others, even family?

3) Are you angry or irritable much of the time?

4) Do you have nightmares about things that happened during the war?

5) Do you jump at noises when others do not?

6) Do you try to avoid thinking about what happened during the war?

7) Do you feel tense or on guard much of the time?

8) Have you repeatedly tried to remember important parts of the war but have not been able to do so?

9) Have you become upset when you heard things that reminded you of the war?

10) Over the years, have you wanted to be alone rather than with others?

Of the 142 Ranfurly residents, 75 met the criteria for further investigation. Out of these, four refused to participate, three died before the screening, two were discharged before screening, one was unable to answer and another was unable to focus on the questions. This made 64 patients/residents involved in our screening. Of these, 27 had positive results to three or more questions; 22 had positive responses to one to three questions; and 15 had no positive responses. By the time the results had been collated, one had died and three were discharged.

The next step in this process to confirm a diagnosis of PTSD (according to DSM-IV) is to administer the clinician-administered PTSD scale (known as CAPS). This takes about one hour per person and the results need to be read by a psychiatrist. At this point, we have not proceeded with CAPS, as we are trying to source funding and then we need to know how to deal or treat those with PTSD. It was clear there was a need to pursue a formal PTSD diagnosis and treatment with a psychologist. Ranfurly is now looking at establishing a veterans' centre with outpatients department, including a clinic to treat PTSD. While many war veterans are treated privately for the disorder (funding is available through War Pensions), there is no national centre in New Zealand, as in Melbourne.

The initial screening showed 20 percent of our veterans have PTSD symptoms. However, this number, in reality, could well be higher. For instance, the question "Do you try to avoid thinking about what happened during the war?" was, in all cases, answered "no". At special events such as Anzac Day, however, attendance is poor. As several veterans have told me, they do not want to go to such a service as it "brings back too many unpleasant memories". Television programmes showing wars in Bosnia, Iraq etc also trigger unsettled and sometimes aggressive behaviour.

Nightmares and sleep disturbances, as part of PTSD, are common, with many of the veterans awake during the night or rising early. It is not uncommon to see them showering, washing and dressing at 5am. Is this part of the ingrained regimented military life or PTSD?

PTSD is evident among the veterans in our care and greater knowledge is needed to understand the special care they require. I believe an accurate assessment on admission is essential. This should include: a full military history; exploration of traumatic events triggering illness; specific questioning to evoke memory and arousal; corroborative history from the spouse; alcohol consumption; family relationships; occupational history; cognitive testing; structured diagnostic interview, eg CAPS; physical examination; clinical investigation (thyroid function etc.); and neuro-psychological testing where indicated.

A full history and assessment would mean treatment and care instigated to deal with PTSD. The assessment would also identify available and potential social supports. However, the biggest single problem is that service people, and in particular prisoners of war, minimise rather than exaggerate their symptoms. Direct questioning about typical PTSD symptoms is essential before the diagnosis can be excluded in any veteran, no matter how old. Staff education is also a priority to help them understand the potential and actual problems these people suffer.

There is a general public misconception that "Dad" or "husband" wants to come to Ranfurly so they can talk about their war experiences. This does not happen. While the comradeship of similar back grounds does exist, close relationships and chats about these do not occur. However, with all patients and residents having their military service numbers displayed on their bedroom doors, there is often an interest among them as to who served in what service. Rank, however, is not displayed.

The defence forces' hierarchical system still persists, with registered nurses and, in particular, me, highly respected. I am still "matron" to many of them and I accept this term of endearment and respect without comment. When introducing myself to new residents, I still use the term "matron", as veterans understand what this position means. The valuable work undertaken by nurses during the war is still remembered with admiration.

Frequent enquiries from media and school children to interview "old soldiers" are carefully screened. Sadly, veterans rarely respond to such requests. The war experiences, losses and memories, will often remain a closely guarded secret, too painful to discuss. It is often not until we attend a veteran's funeral that we learn some of the war "secrets" that the veteran will take to his grave--acts of heroism, decorations received for bravery, torture and trauma suffered at the hands of the enemy, being part of the resistance or underground movement, and escaping from prisoner of war camps. What a story these veterans could have told and, if we had known, perhaps we could have helped ease their pain.

I would like all those who nurse or care for veterans to look at them through different eyes. Perhaps your "grumpy old man" or "difficult person" is one of the "silent suffering" who needs understanding and love. A clear understanding of PTSD and the war will help staff deal with this syndrome. Pertinent education, both for registered and unregistered staff, should be included in our programmes. This is particularly important when over half our caregivers will have no family knowledge of war and its effects.

Can PTSD be treated? Not all people who experience trauma require treatment. Most are able to recover with the help of family and friends. Some, however, who experienced severe events or had other problems in their life at the time, may need professional help. Left untreated, PTSD can become a chronic disabling disorder, so early effective diagnosis and treatment are important. This help should be sought, when a person:

* experiences problems that are severe or last for more than a month;

* is constantly on edge or irritable;

* has difficulty responding emotionally to others;

* increasingly uses alcohol or other drugs

* becomes unusually busy to avoid dealing with issues; and

* has a strong need to share experiences, but no-one is available or able to listen.

Many treatments are available including a range of strategies:

Education: to improve understanding about common reactions to trauma and why they have the symptoms they do.

Stress management: to assist in managing distress. This may include specific treatment for alcohol/drug use/anger management.

Dealing with the memories: to enable the survivor to confront what has happened Drug treatment: a range of medication may be used, including long-term treatment. Medication on its own will not change the underlying problems and should be combined with other treatments.

Our community at Ranfurly is very special. The veterans need the same love and care as any other older person but this needs to be accompanied by understanding and knowledge of the battle trauma they survived.

In conclusion, one must ask whether war veterans are victims or heroes. My answer is a categorical "yes" in both instances. A person who has suffered the atrocities of war, death of comrades, killing the enemy, starvation and physical abuse while serving their country, must be suffering, whether this is obvious or not.

REFERENCES

(1) Bille, D. A. (1993) Road to recovery--posttraumatic stress disorder: the hidden victim. Journal of Psychosocial Nursing; 31: 9, 19-28.

(2) Statistics New Zealand. 1996 Census of Population and Dwellings. Wellington: New Zealand Government.

(3) Calder, P. (1999) Shell Shock by Any Other Name. The New Zealand Herald, April 15. Auckland: Fairfax New Zealand Ltd.

(4) Bonwick, R. and Morris, P. (1996) Review: Post-traumatic stress disorder in elderly war veterans. International Journal of Geriatric Psychiatry; 2, 1071-1076.

--Melva Nicholson, RGON, is manager nursing services at Auckland's Ranfurly War Veterans' Home and Hospital. This article is based on a presentation she gave at the 12th Canadian Gerontology Conference in Kelowna, British Columbia, last year.