The Gerontologist
cite as: Gerontologist, 2016, Vol. 56, No. 1, 1–4
doi:10.1093/geront/gnv671
Special Issue: Veterans Aging: Editorial
Veterans Aging
Rachel Pruchno, PhD
Editor-in-Chief, The Gerontologist, Director of Research, New Jersey Institute for Successful Aging, Rowan University
School of Osteopathic Medicine
*Address correspondence to Rachel Pruchno, PhD, Editor-in-Chief, The Gerontologist, Director of Research, New Jersey Institute for Successful
Aging, Rowan University School of Osteopathic Medicine, Stratford, NJ 08084; E-mail: [email protected]
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
© The Author 2016. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved.
For permissions, please e-mail: [email protected].
1
2
(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.
The Gerontologist, 2016, Vol. 56, No. 1
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
The Gerontologist, 2016, Vol. 56, No. 1
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 MiniMental 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
3
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 internetdelivered distance program (Tele-Savvy). Results of initial
implementation indicate that Tele-Savvy was successful in
4
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.
References
Black, H. K. (2016). Three generations, three wars: AfricanAmerican veterans. The Gerontologist, 56, 33–41. doi:10.1093/
geront/gnv122
Davison, E. H., Kaiser, A. P., Spiro, A., Moye, J., King, L. A., & King,
D. W. (2016). From late-onset stress symptomatology (LOSS) to
later-adulthood trauma reengagement (LATR) in aging combat
veterans: Taking a broader view. The Gerontologist, 56, 14–21.
doi:10.1093/geront/gnv097.
Dursa, E. K., Reinhard, M. J., Barth, S. K., & Schneiderman, A. I.
(2014). Prevalence of a positive screen for PTSD among OEF/
OIF and OEF/OIF-era Veterans in a large population-based
cohort. Journal of Traumatic Stress, 27, 542–549.
Green, E., Fairchild, J. K., Kinoshita, L. M., Noda, A., & Yesavage,
J. (2016). Effects of posttraumatic stress disorder and metabolic
syndrome on cognitive aging in veterans. The Gerontologist, 56,
72–81. doi:10.1093/geront/gnv040
Griffiths, P. C., Whitney, M. K., Kovaleva, M., & Hepburn, K.
(2016). Development and implementation of Tele-Savvy for
dementia caregivers: A Department of Veterans Affairs Clinical
Demonstration Project. The Gerontologist, 56, 145–154.
doi:10.1093/geront/gnv123.
Hardy, M. A., & Reyes, A. M. (2016). The longevity legacy of
World War II: The intersection of GI status and mortality. The
Gerontologist, 56, 104–114. doi:10.1093/geront/gnv041
The Gerontologist, 2016, Vol. 56, No. 1
Kang, S., Aldwin, C. M., Choun, S., & Spiro, A. (2016). A lifespan perspective on combat exposure and PTSD symptoms in
later life: Findings from the VA Normative Aging Study. The
Gerontologist, 56 ,22–33. doi:10.1093/geront/gnv120
Karel, M. J., Teri, L., McConnell, E., Visnic, S., & Karlin, B. E.
(2016). Effectiveness of expanded implementation of STAR-VA
for managing dementia-related behaviors among veterans. The
Gerontologist, 56, 126–138. doi:10.1093/geront/gnv068
Levy, C. R., Alemi, F., Williams, A. E., Williams, A. R., Wojtusiak, J.,
Sutton, B., … Argyros, L. (2016). Shared homes as an alternative to nursing home care: Impact of VA’s medical foster home
program on hospitalization. The Gerontologist, 56, 62–71.
doi:10.1093/geront/gnv092
Levy, C. R., Zargoush, M., Williams, A. E., Williams, A. R., Giang,
P., Wojtusiak, J., … Alemi, F. (2016). Sequence of functional loss
and recovery in nursing homes. The Gerontologist, 56, 52–61.
doi:10.1093/geront/gnv099
National Center for Veterans Analysis and Statistics. (2014). Veteran
Population Projections Model. Retrieved from http://www.
va.gov/vetdata/veteran_population.asp
National Center for Veterans Analysis and Statistics. (2015). Profile
of Veterans: 2012 Data from the American Community Survey.
Retrieved from: http://www.va.gov/vetdata/docs/SpecialReports/
Profile_of_Veterans_2012.pdf
Nichols, L. O., Martindale-Adams, J., Burns, R., Zuber, J., & Graney,
M. J. (2016). REACH VA: Moving from translation to system
implementation. The Gerontologist, 56.
Padula, C. B., Weitlauf, J. C., Rose, A., Reiber, G., Cochrane, B. B.,
Naughton, M. J., . . . Espeland, M. A. (2016). Longitudinal cognitive trajectories of women veterans from the Women’s Health
Initiative Memory Study. The Gerontologist, 56, 135–144.
doi:10.1093/geront/gnu112
Sachs-Ericsson, N., Joiner, T. E., Cougle, J. R., Stanley, I. H., &
Sheffler, J. L. (2016). Combat exposure in early adulthood
interacts with recent stressors to predict PTSD in aging male
veterans. The Gerontologist, 56, 83–91. doi:10.1093/geront/
gnv036
Settersten, R. A. (2006). When nations call: How wartime military
service matters for the life course and aging. Research on Aging,
28, 12–36. doi:10.1177/0164027505281577
Settersten, R. A., & Patterson, R. S. (2007). Military service, the life
course, and aging: An introduction. Research on Aging, 28, 12–
36. doi:10.1177/0164027505281579
Spiro, A., Settersten, R. A., & Aldwin, C. M. (2016). Long-term
outcomes of military service: A positive re-envisioning of its
place in aging and the life course. The Gerontologist, 56, 5–13.
doi:10.1093/geront/gnv093
Taylor, M. G., Ureña, S., & Kail, B. L. (2016). Service related exposures and physical health trajectories among aging veteran men.
The Gerontologist, 56, 92–103. doi:10.1093/geront/gnv662.
U.S. Department of Veterans Affairs. (2011). Gulf War era Veterans
report: Pre-9/11. Retrieved from: http://www.va.gov/vetdata/
docs/SpecialReports/GW_pre911_report.pdf
Wojtusiak, J., Levy, C. R., Williams, A. E., & Alemi, F. (2016).
Predicting functional decline and recovery for residents in
Veterans Affairs nursing homes. The Gerontologist, 56, 42–51.
doi:10.1093/geront/gnv065