The Impact of Event Scale– Revised

Overview A person may suffer debilitating anxiety and other physical and psychological symptoms without recognizing that they're a response to a traumatic event. And older adults in particular may be reluctant to admit to experiencing such symptoms. The Impact of Event Scale–Revised (IES-R) is an easy-to-administer questionnaire used to evaluate the degree of distress a patient feels in response to trauma. It provides a structured way for a patient to communicate distress when she or he may not have the words to do so. For a free online video showing nurses using the IES-R with an older patient, go to links.lww.com%2fA316. Four months after 93-year-old Teresa Albini moved into a nursing home in West Palm Beach, Florida, Hurricane Frances brought torrential rains and wind gusts of 120 miles per hour. When the hurricane came ashore, the force felled trees on the facility's grounds; one landed on the roof of Ms. Albini's wing. (This case is a composite of several that occurred during the hurricane seasons of 2004 and 2005.)FigureBut a day before the hurricane was expected to make landfall, after predictions that the storm would intensify, the administrator decided to evacuate residents to a facility in Tampa—a two-hour trip under normal circumstances. Along with the nearly 100 other residents being transported, Ms. Albini was given a wristband specifying her name and medications, and was told to pack enough clothes for a two-day stay. By the time the buses got on the road, however, traffic was bumper-to-bumper, and it became clear that the residents wouldn't be going to Tampa that day. After four hours in traffic, wind, and rain, the buses stopped at a temporary shelter set up in a community gymnasium in a small inland town. The shelter was noisy, and Ms. Albini and the other residents slept on inflatable mattresses placed on the floor. At 1:45 AM, they were awakened by alarms and a warning of tornados. In fear for her life, Ms. Albini cried as she listened to the thundering winds outside. By morning, the eye of the storm had passed and the threat of tornados diminished. The trip to Tampa was resumed. read it | watch it | try it Web Video Watch a video demonstrating the use of the Impact of Event Scale–Revised at links.lww.com%2fA316. A Closer Look Get more information on why it's important for nurses to assess for posttraumatic stress disorder in older adults, as well as why the Impact of Event Scale–Revised is a good approach for doing so. Try This:The Impact of Event Scale—Revised This is the scale in its original form. See page 66. Online Only Unique online material is available for this article. A URL citation appears in the printed text; simply type it into any Web browser. A week after arriving in the Tampa facility, Ms. Albini learned that although other residents had returned home, she wouldn't be able to for four months—damage to her wing of the building would take at least that long to repair. As a "temporary" resident of the Tampa facility, she would need more clothing; volunteers went to a local discount department store for clothes and toiletries. Although Ms. Albini was grateful, she was also distressed by their choices: she'd spent decades wearing designer clothes. She told friends that she wanted garments "as nice" as those she was used to. She was also worried about the keepsakes that were in her room and wondered whether they'd been destroyed when the tree fell. Now, one month later, Ms. Albini reports having problems sleeping and refuses to eat, saying that her stomach is upset all the time. Her chart shows that she has arthritis in her knees, hips, and hands; degenerative joint disease; osteoporosis; and high blood pressure. She walks short distances without assistance but needs a walker to go to meals or attend activities. Her score of 28 on the Mini-Mental State Exam is within normal limits. She takes several prescribed medications: metoprolol (Lopressor and others) and amlodipine (Norvasc) to manage high blood pressure, acetaminophen (Tylenol) 650 mg twice per day for arthritis pain, alendronate (Fosamax) for osteoporosis, and tolterodine (Detrol) for urinary incontinence. After conducting a complete evaluation, her physician says that he can find no medical reasons for her symptoms. He confers with the nurse manager, and they decide that Ms. Albini should be assessed for symptoms of stress related to her experiences during the hurricane. They decide to use the Impact of Event Scale–Revised (IES-R). (To watch the portion of the online video in which a nurse administers the IES-R and brings her findings to a team meeting to discuss how to help the patient, go to links.lww.com%2fA317. THE IES-R The IES-R is a self-administered, 22-item questionnaire based on three clusters of symptoms identified in the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III), as indicators of posttraumatic stress disorder (PTSD).1 * Intrusion is assessed with eight items on the scale. * Avoidance is assessed with eight items on the scale. * Hyperarousal is assessed with six items on the scale. The IES-R is not a diagnostic or screening tool for PTSD; rather, it relies on a patient's own report of symptoms and is used to gauge response no sooner than two weeks after a traumatic event, as well as to evaluate recovery. (The National Center for PTSD defines a traumatic experience as one that "typically involves the potential for death or serious injury resulting in intense fear, helplessness, or horror." Examples of such experiences include natural disaster, terrorist attack, or physical or sexual assault. For more information go to www.ncptsd.va.gov.) Those assessed with the IES-R are asked to indicate the degree of their distress for each of 22 symptoms according to a five-point scale: 0 indicates that the symptom occurs "not at all"; 1, "a little bit"; 2, "moderately"; 3, "quite a bit"; and 4, "extremely." The 15-item IES was first published in 1979,2 a year before the DSM-III was published (the first edition to include a diagnosis of PTSD). The IES-R was published in 1997. It should be administered once it has been determined that symptoms—whether physical, such as a digestive problem or a headache, or nonspecific or cognitive, such as intrusive thoughts, flashbacks, or nightmares—are most likely due to trauma and have no other medical basis. (For more information on when to use the IES-R, go to links.lww.com%2fA558.) Determining whether a symptom is a result of trauma requires inquiry into recent experience, and we recommend the IES-R as the most effective approach when used after a recent trauma. And an advantage of using a questionnaire like the IES-R is that it gives patients a means to communicate distress when language or insight eludes them. (See Why Assess Older Adults After a Traumatic Event?7–9 on this page.) Translations. The IES-R has been translated into Chinese, Japanese, French, and Spanish; a version has also been created for Sri Lanka.3–6 ADMINISTERING THE IES-R Establishing rapport with the patient is essential, although it can be made difficult by the patient's mistrust, hypervigilance, shame, anger, and avoidance, all of which can be induced by trauma. A normal response immediately after a trauma can include intense levels of stress. Such immediate responses aren't good predictors of how well the patient will cope or of the eventual risk of developing PTSD. People who are highly symptomatic—those who startle easily, are unable to sleep, or report flashbacks or feeling numb—two weeks after a traumatic event are at risk for PTSD. Ms. Albini's nurse begins with the following: "Ms. Albini, I've noticed that you seem anxious. You've said that your stomach is upset and you're having a hard time sleeping. Sometimes people have such difficulties after stressful events. You've been through a lot with the hurricane, the terrifying tornado, and this unexpected relocation. I think this questionnaire could help us understand these difficulties. You should read each item on this list and then indicate how distressing each has been for you during the past week." She explains that each item refers to a person's distress level in response to recent traumatic events. She describes the rating system, asking Ms. Albini to numerically rate her responses, and after she answers the first question the nurse says, "I'll come back in about 20 or 30 minutes to review your answers with you." Upon return the nurse looks at the scores within each subscale and talks with Ms. Albini about her responses. The nurse calculates a mean score for the eight questions on the intrusion subscale of 2.5—between "moderate" and "quite a bit"—and discusses these questions. For intrusion—the reliving of the hurricane and tornado—Ms. Albini says that she's been having reminders that bring up feelings about the hurricane, difficulty staying asleep, thoughts about the hurricane when she doesn't want them, pictures of the tornado popping into her mind, and dreams about the tornado, "quite a bit." She tells the nurse that other things like the clothes the nursing home staff bought for her reminded her of the hurricane, and that she experienced "moderate" distress with waves of strong feelings. She felt like she was back at the hurricane evacuation "a little bit." Her mean avoidance subscale score was 3.6 (she did not answer two of the questions on avoidance). While discussing these questions, Ms. Albini said she did not want to do normal activities and was "extremely" distressed and stayed away from reminders of the tornado and tried not to think or talk about it, wanting to remove it from her memory. She felt "numb" and realized she had feelings but didn't want to deal with feelings "moderately." She reported that she didn't want to go to church or any outside events because they made her think about the hurricane. Finally, her hyperarousal subscale score was just below 1. She told the nurse that she was irritable and jumpy and had trouble falling asleep and concentrating, and reminders like her new clothes kept making her think about the evacuation. Her heart pounded "a little bit," but she was watchful "not at all." CHALLENGES THAT MAY ARISE Before administering a questionnaire to a patient, it's important to ask about the highest grade level the patient completed. Using the Flesch–Kincaid Readability tool, we determined that several of the items on the IES-R exceed a ninth-grade reading level. If the person reports ending school before the 12th grade, ask her or him to read a question and paraphrase it. If the patient can't do so, the IES-R should be administered by interview. In addition, older adults with visual impairment should receive a copy of the IES-R that is printed in at least 14-point type; again, if that isn't sufficient, the questions can be read aloud. The IES-R is not appropriate for people with moderate or severe memory impairment. People with moderate dementia (a Mini-Mental State Exam score of 22 or lower) can't complete the questionnaire because short-term memory is required. SCORING AND INTERPRETING THE RESULTS The total score for each subscale should be calculated using the mean of the scored responses. Scores will range from 0 to 4; responses that receive a rating of 0 (but not the items the patient didn't endorse) should be figured into the mean. The amount of distress the patient is experiencing corresponds, therefore, to the categories on the scale; for instance, a patient with a mean score of 3 in avoidance displays "quite a bit" of avoidance behavior. But too much emphasis should not be placed on a person's total score; it should be remembered that function is more important than an absolute score, especially in older adults. And because most older adults will not receive high scores in all three subscales, any dysfunction revealed by the screening should indicate a need for referral for further evaluation and counseling (the nurse administering the IES-R will not have to provide counseling). We've found that after a traumatic event older adults are usually relieved when clinicians try to help and are quite willing to work with them. When making a referral, the nurse should specify which areas the patient said were most distressing. The initial goals of therapy are to relieve symptoms, enhance coping skills, and instill hope that previous functioning will return. High scores on all three subscales indicate the need for further evaluation for past trauma—such as a history of childhood or spousal abuse, combat trauma, or interpersonal violence, any of which might exacerbate the response to a current trauma—or other psychiatric disorder such as depression or anxiety. Kessler and colleagues found that people with PTSD have a higher rate of other psychiatric disorders than those who don't have PTSD.10 Weiss indicates that a number of factors influence the scores obtained on the scale; for example, the time that has elapsed between the traumatic event and the administration of the questionnaire influences the reporting of symptoms (the more recent the event, the higher the number of symptoms reported).11 The severity of the traumatic event also influences scores: more severe traumas result in more extreme symptoms. Finally, Weiss states that scores are influenced by a "base rate of stress reactions" in the sample studied (for example, firefighters who are trained to deal with trauma will have less severe symptoms than civilians). Thus, Weiss writes, "it is simply inappropriate" to require or to attempt to set universal cutoff points for scoring, and clinicians should remember that the scale is not intended to diagnose PTSD. For nurses working with distressed patients over an extended period, the IES-R can be a helpful way to monitor symptom frequency and intensity. By administering the scale repeatedly, the clinician can track progress and gauge response to interventions. If the patient is progressing slowly, a reevaluation might occur every four or five visits. But if the patient is highly distressed, it might be done more often. (To view the portion of the online video in which experts are interviewed about symptoms of PTSD and treatment goals, go to links.lww.com%2fA318. Ms. Albini's mean intrusion score was 2.5—between "moderate" and "quite a bit." Her mean score on the avoidance subscale was 3.6. Her hyperarousal score was low, however, being slightly below 1 on the five-point scale. After calculating the scores, the nurse says, "I can see by the way you answered these questions that you are distressed after the tornado and the evacuation. You seem to be reliving the experience and avoiding your normal activities quite a bit. Some patients who have had similar experiences have benefited from talking to a counselor. I think it would be worthwhile for you to give this a try. I'm suggesting a few sessions with the social worker to see if you feel less anxious after talking to her about these experiences. I'd like to make an appointment with Regina Scott; is that okay with you?" Ms. Albini agrees to counseling. COMMUNICATING THE FINDINGS Sharing IES-R results with the patient as treatment progresses might be therapeutically useful: the patient can see that symptoms are being alleviated over time. If on the other hand the number or intensity of symptoms increases, a review of the treatment plan might be necessary. Likewise, if symptoms are inconsistent over time, the clinician might want to consider whether the patient is a reliable source or is or whether other factors are responses. 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