Clinicians should consider cumulative hardships in optimizing treatment during patients’ final years

Repeating a school year, experiencing parental abuse or engaging in armed combat have far-reaching long-term effects. Lifetime trauma may even worsen end-of-life pain and discomfort, depression and loneliness.

These are some of the main findings from the Health and Retirement Study, which followed approximately 6,500 Americans over 50 who died from 2006 to 2020. The study, led by the University of Michigan and the University of California, San Francisco, is published in the Journal of the American Geriatrics Society.

For author Kate Duchowny, a researcher at the U-M Institute for Social Research, trauma “gets under the skin.”

“We know that trauma is associated with depression and anxiety, which may promote a pro-inflammatory environment that is associated with chronic conditions,” she said. “Persistent stress can lead to inflammation and adverse health consequences in later life.”

Co-author Ashwin Kotwal of the UCSF Division of Geriatrics and the San Francisco VA Medical Center said that early-life trauma, in particular, especially physical abuse by parents, was strongly related to end-of-life pain, loneliness and depressive symptoms.

“Traumatic events in childhood may have reverberating effects throughout the lifespan,” he said. “They may play a role in social and emotional isolation, poor health habits and an increased risk of subsequent trauma.”

Study participants completed a questionnaire about their experiences with 11 traumatic events, as well as their psychosocial well-being. They were interviewed every other year until death, at an average age of 78. A final “exit interview” with a family member or friend with power of attorney provided information about symptoms in their last year.

Repeating a grade: A common practice with long-lasting impacts

Duchowny, Kotwal and colleagues found that 2 in 5 participants experienced childhood trauma, which also included getting into trouble with the police and exposure to family members’ drugs or alcohol abuse. The most common potentially traumatic event in childhood was repeating a school year.

The most common causes of trauma in adulthood were a prior life-threatening illness or a life-threatening illness of a spouse or child. Less common were death of a child, having a partner with drug addiction, surviving a natural disaster or engaging in armed combat. More than 80% of participants experienced at least one lifetime trauma and 1 in 3 experienced at least three.

Participants who reported that they had no experience of trauma had a 46% probability of end-of-life moderate-to-severe pain and a 12% probability of loneliness. This compares with 60% and 22%, respectively, for those who had experienced at least five traumatic events.

Depression was also markedly lower among participants who hadn’t experienced trauma. They had a 24% probability of end-of-life depression versus 40% for those who had been through five or more traumatic events.

“While a strong social gradient has been observed across numerous health outcomes—that is, individuals who are less advantaged often have worse health profiles—our results show traumatic events are ubiquitous,” Duchowny said.

“Experiencing trauma cannot necessarily be offset by social resources and it is often not a question of if, but when, individuals will be exposed and to what extent this may impact their quality of life at older ages.”