Phase 3 of the implementation schedule for the Mega Rule go into effect in November of this year. Phase 2 and 3 require facilities to demonstrate staff competencies and skill sets based on resident population, as well as providing training to remediate identified knowledge gaps.   Part of these Requirements include Trauma Informed Care (TIC).  This in an introductory discussion about how these changes will impact care delivery in the future.

Historically speaking, populations that have been served by staff experienced with treating traumatic issues include youth and children.  Lifelong impact of trauma during developmental periods has been well documented.  Secondly, trauma care treatment has been focused on our military, PTSD is a prominent diagnosis that focuses on impact trauma will have in daily life. 

Recent discussions within the Geriatric Care Provider Organizations have included impact of trauma in elderly and benefits of receiving care that focuses on behavioral health and/or post traumatic stress disorders.  With the increase in awareness of the benefits coupled with drive to ensure person centered care is being delivered comes the need to increase the educational exposure for staff caring for the aging populations.

 A potentially traumatic event is one that will affect your daily life.  Take for example how a devastating weather event, destructive tornado, hurricane, or flood may have had significant impact on someone’s life and their current reaction to severe weather.  Per Leading Age “A majority of us- somewhere between 55% and 90% by some measures- have experienced at least one traumatic event.”   Examples of traumatic experiences could include experiencing or witnessing domestic and sexual violence, car, train, plan crashes, combat, becoming a refugee, homelessness, medical trauma, violent crime, discrimination, and numerous other potentially harmful life events.

The mere thoughts of 90% of our population having exposure to a traumatic event is staggering.  Knowing that situations occur in everyday life that may trigger those memories and affect patient responses is imperative to assist with care.  As caregivers, how we react when those memories are triggered may make all the difference in the world to the patient’s ability to actively participate in care.

Many times, in older adults when those memories are triggered it may result in responses by the elder that could be easily misdiagnosed.  Behaviors such as irritability, argumentative and confusion, could lead to medication prescriptions that are not necessarily appropriate.  Treating behavior instead of underlying cause.  It is increasingly important that employees in LTC environment are aware of trauma informed care principles to keep those at risk safe.

Start off by defining trauma and look at the components of trauma.

Trauma:  Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.


The Three E’s of Trauma: The Three E’s of Trauma are event(s), experience of event(s) and effect.

EVENTS — can include actual or extreme threat of harm, or severe, life-threatening neglect for a child. Events can occur once or repeatedly over time.

EXPERIENCE — how the individual experiences an event helps determine if it is a traumatic event. Does recall of the event disrupt normal behavior?  Does recall of the event trigger feelings of humiliation, shame, guilt? Is there a Cultural component that is affected? Has there been social or psychological support in the past?

EFFECT — adverse effects can occur immediately or after a delay and can have a range of duration. Individuals may not recognize the connection between traumatic events and their effects.

Adverse effects include:

  • Inability to cope with normal stresses of daily living
  • Inability to trust and benefit from relationships
  • Cognitive difficulties — memory, attention, thinking, self-regulation, controlling the expression of emotions
  • Hypervigilance / hyperarousal, numbing, avoidance

The first step towards being able to provide adequate trauma-informed care is a basic understanding.  We’ve provided you with facts regarding trauma and how patients may present if actively dealing with traumatic situations.  Let’s next look at how to effectively deal with patients experiencing trauma associated symptoms.

TRAUMA-INFORMED: What does this mean?

With basic understanding of trauma, next we’ll focus on recognition that past trauma may never have been dealt with and that triggering behaviors may be misinterpreted many ways.  Providing a fully integrated Trauma-Informed program will assist in preventing re-traumatization to individual.

The trauma informed approach can be broken down into four components.  All employees must be able to have a working knowledge of the following components.

The Four R’s.

Realization:  All employees realize that trauma can affect individuals, families, organizations, and communities. Individual behaviors may be coping strategies used to survive adversity and overwhelming circumstances both past and present.

Recognition:  All employees can recognize the signs of trauma and have access to trauma screening and assessment tools.

Responding:  With increased awareness of specific resident experiences, all employees can provide care using trauma informed approaches.

Resisting:  Understanding the impact of creating a potentially toxic environment by using devices such as restraints or seclusion with residents who have a trauma history.

Alison Mitchell, MA, MSW and Len Kay, Ph.D., DSW of the University of Maine Center on Aging have developed core principles outlining guidance for trauma-informed care.  We will review the three core principles in detail.

Principle 1: The impact of adversity is not a choice.  The old adage of “what doesn’t kill you makes you stronger” is not necessarily true.  Even one acute traumatic experience, sometimes called a single incident trauma, can change the brain in harmful ways.  In addition, your genetic makeup plays a part in how you deal with stressful situations.  The genetic makeup you inherit makes some of us more likely than others to experience difficult events as traumas that, in turn, produce health-damaging traumatic stress.

Principle 2: Understanding adversity helps us make sense out of behavior. Without understanding that prior adverse events may manifest as behaviors in the elderly population, the likelihood of going undetected and possibly treated incorrectly goes up.

Principle 3: Prior adversity is not destiny.  The ability of the human brain to continue to learn and grow lasts throughout life, this is known as neuroplasticity.  In a safe and supportive setting, elderly patients can learn new coping mechanisms and how to deal constructively with adversity.

Identify the Presence of Prior Trauma and Triggers

What then, is the best approach to teach staff?  How might we adjust our daily tasks to ensure that patients are thoroughly assessed and screened for prior trauma and staff respond appropriately?  It must start with an assessment that will ferret out history of trauma.  Lisa M Brown, PhD Director of Trauma Program at Palo Alto University suggests using questions such as:

some patients have told me about difficult experiences they had during their lifetimes, such as being threatened or ___.  Has anything like that ever happened to you?”

Opening that vein of communication will help get a better understanding and begin to allow you to incorporate strategies in daily care.  Always validate the response: “That must have been very frightening”.  Make certain that you respond with a response that normalizes the event: “You are not alone.”  “Many people have had these experiences and may feel angry, embarrassed, fearful, etc.”

It’s inappropriate to probe the patient for details at this point.  You should not respond by questioning the patient “if that really happened” or if they are in some way responsible for the incident.  Helpful, trauma-informed care individuals will validate the incident back with the patient.

Only three questions, the briefest screen ever was introduced by Gabriella Grant of the CA Center of Excellence for Trauma-Informed Care.

  • Do you feel safe speaking with me today? If not, what would help you feel safer?
  • Do you feel safe being here/living here today? If not, how can we help you feel safer?
  • Did you feel safe at home as a child? If not, how does that affect you today?

If you are unable to ascertain that there is a history of trauma the best approach is to assume there is.  Using specific therapeutic interactions, the answer may become clearer and direct care based on responses.  Gabriella Grant also recommends specific responses, such as recognizing bravery for coming forward with troublesome information, recognizing the disclosure was difficult, redirect the elder to the present if trauma occurred in early life.  You must also be aware of reporting responsibilities, if this is new information to your care team, ensure it is reported up through the supervisory system where mandated State reporting can occur if applicable.

Understanding what triggers memories of traumatic event is helpful to prevent re-traumatization. Triggering the memory is not always easily identifiable. It could be a scent, a sound, something seen, or felt.  The act of revisiting the incident could stimulate the patient to react in manner that feels as if the incident/insult is fresh.  The goal is helping the patient understand what stimulates and then preventing triggers.

De-escalation techniques should be focused on ensuring the patient is safe from injury.  Staff need to understand that often the patient’s response to the memory will bring back memories of the time and place and may require assistance to bring the patient back (psychologically and emotionally) to the here and now.  As with all patient care, this requires individual plan of treatment and approach.  As, what may work with one individual may not with another.  For continuity, it is best to keep a written plan to address de-escalation techniques and share with the treatment team.

Organizations should be ensuring that your team has an understanding how exposure to prior trauma can affect patients later in life.  Putting these concepts into practice will help position your organization to successfully address patients who may be affected by trauma.  Provision of trauma-informed care starts with understanding and effectively assessing for it’s presence.  Organizations that invest in leadership who will champion this initiative will successfully be able to address the patient’s needs. 




Leading Age Maryland; Foundations of Trauma-Informed Care: An Introductory Primer