When the body speaks during wartime: Clinical presentation of older vs. younger adults in psychiatric emergencies during wartime

Introduction: Mass trauma events have documented psychiatric consequences across all ages, and with an aging global population, more older individuals will face disasters, increasing the psychiatric burden. Reactions to trauma include post-traumatic stress disorder and exacerbation of pre-existing disorders. Research on age-related trauma vulnerability shows mixed results, with some studies indicating higher vulnerability in older adults, and others suggesting greater resilience. Older adults may present stress symptoms as somatic complaints rather than emotional distress. However, their unique psychiatric presentation remains understudied, especially in emergency settings. The aim of this cohort study is to compare clinical characteristics and emergency department (ED) arrival reasons between older adults (≥60 years) and younger adults (18–59 years) following Israel's October 7, 2023 armed assault and with historical controls from the previous year. Methods: The study examined psychiatric patients who visited Sourasky Medical Center's ED during two 30-day periods: “wartime” (October 7–November 5, 2023) and “controls” (October 17–November 15, 2022). Excluded were patients brought by police or with primary physical injuries. Data from medical records included demographics, clinical characteristics, self-referral status, prior mental illness, ED diagnosis, suicidal ideation, and visit reasons. Statistical analyses compared outcomes across age groups and periods. Ethical approval was obtained. Results: During wartime, psychiatric ED visits increased by 65% (230 visits) compared to the control period (139). Older adults saw an 80% increase, while younger adults had a 64% increase. The proportion of self-referrals remained similar across both periods (72% vs. 75%, p=), but older adults compared with younger adults were less likely to self-refer during wartime (56% vs. 74%, p = 0.047). The total proportion of patients with a prior psychiatric diagnosis was lower during wartime than in the previous year (66% vs. 89%, p > 0.001). Fewer patients with severe mental illnesses were presented during wartime compared with the previous year (18% vs. 32%, p = 0.001), with younger adults showing a more significant decrease between the wartime and control periods (34% vs. 16%, p < 0.001). More patients were diagnosed with trauma-related disorders during wartime compared with the control period (72% vs. 50%, p < 0.001), particularly younger adults, while older adults showed stable rates. Suicidal ideation was lower during wartime compared with the previous year (8% vs. 15%, p = 0.03), especially in older adults. During the control period, older adults were slightly more likely than younger adults to have a somatic chief complaint (33% vs. 24%, p = 0.31). However, during wartime, this difference widened significantly (44% vs. 16%, p = 0.001). Conclusions: These findings suggest that psychiatric symptoms in older adults may be underdiagnosed, as they are often masked by physical complaints, emphasizing the need for clinicians to consider underlying psychological distress during crises.