Ageing Holocaust survivors in Australia

The harsh environment of the Holocaust had dramatic psychosocial effects on many survivors’ concepts of health, creating an ingrained belief that perfect physical health was necessary to survive.9 Consequently, some survivors experience disproportionate anxiety when informed that they require standard non-invasive geriatric aids such as walking sticks, dentures, glasses and hearing aids. The idea that they are becoming weaker may be challenging to their self-image as “the ultimate survivor”.10

Several studies have found that Holocaust survivors cope much worse than controls with diagnoses of disease. A retrospective analysis of 106 patients matched for sociodemographic and medical background showed that survivors diagnosed with cancer exhibit disproportionate psychological distress, are less able to mobilise partial denial and score higher on avoidance and intrusiveness, culminating in worsened psychosocial outcomes.11 One limitation of this study was a lack of data on participants’ premorbid psychological function.

In a comparative study of 66 survivors and controls with chronic pain, survivors reported higher pain levels, more pain sites and significantly higher depression scores.12 Weight loss may be a particularly emotionally invested symptom due to Holocaust memories of emaciation and death by starvation. Likewise, swallowing problems and other causes of dysphagia may provoke fear and distress.

The onset of a decline in coping and psychological distress in old age may erode the will to live. Recent publications have found that older Holocaust survivors with depression are 52% more likely to report suicidal ideation and 2.9 times more likely to attempt suicide than controls with depression.3,4

Among the Australian Holocaust survivor population, the prevalence of PTSD is estimated at 39%.1 Previously identified risk factors for worsened PTSD symptoms among Australian Holocaust survivors include increased age, severity of trauma, use of immature defence mechanisms, and higher neuroticism.13

Dementia is present among 22.4% of people aged 85 years and over.14 Furthermore, Holocaust survivors may be at an elevated risk of vascular dementia owing to an unfavourable cardiometabolic profile (see below).15 Thus, the impact of cognitive decline on Holocaust survivors may be profound on an individual and community level.

With cognitive decline, PTSD severity may worsen as repressed memories in the brain are liberated. Previously high-functioning patients may become “uncontrollable and highly disruptive following the onset of neurologic illness”.5 It is conjectured that cognitive decline “diminishes patients’ capacity to inhibit intrusive traumatic memories . . . resulting in a re-emergence of PTSD symptoms accompanied by intense feelings of anxiety and depression”.5

The sequelae of this phenomenon may be profound. When recalling their experiences, survivors are confronted once more with memories of the deaths of loved ones, and torture at the hands of guards and doctors. They may lose their connection to the family they have created in Australia, and to memories of their post-war success and stability. As dementia progresses, acquired language skills in English may be lost, rendering them less able to communicate with family and medical staff.5

Even for those who do not develop dementia, the life-cycle changes of ageing can still precipitate worsening of PTSD severity. Prototypical stressors of ageing, such as retirement, the loss of a spouse or close friends, health problems and an increased awareness that, once again, death is close, may all drive worsened functioning and increased reporting of PTSD symptoms.2 Similar findings have been noted in participants who were Australian POWs in the Changi Prison camp or on the Burma Railway during World War II.6,7

A Sydney researcher elaborated the reasons underlying survivors’ understandable distrust and fear of the medical profession —

There are many traumatic cues in the medical experience for Holocaust survivors; even calling an ambulance may be psychologically overwhelming. In the 1990s, Melbourne’s Metropolitan Ambulance Service recorded an inappropriately low number of call-outs for chest pain from the suburbs in Melbourne with the highest proportion of Holocaust survivors. It was thought that survivors apparently preferred transport by family members, at the expense of “door-to-needle time”.16

Hospitalisation is a great upheaval commonly experienced by survivors. Traumatic cues include “absence of family members, loss of privacy, increased sense of vulnerability, and invasion of the body by medical examinations”.17 Survivors frequently develop delusions of being in the camps again.10 This may result in an apparently inexplicable extreme fear of medical staff, due to misinterpretation of their actions and motives (Box 1).

Bone disease secondary to starvation (“hunger osteopathy”) was endemic in the Warsaw Ghetto, and was presumably equally if not more common in concentration camps. A 2007 comparative study of 73 female Holocaust survivors and 60 controls, matched for sociodemographic background and risk factors for osteoporosis, demonstrated the long-term impact of this severe nutritional deprivation.19 Of female survivors who were younger than 17 years in 1945, 58% had osteoporosis of the lumbar spine (L2–L4) or neck of femur, compared with 20% of controls — a significant increase in risk by a factor of 3.47.

Exposure to extreme physiological stress during critical periods of development may trigger permanent changes in cardiometabolic, neurological and endocrine function (the “Barker hypothesis”).15 Investigation of cortisol levels among Holocaust survivors has revealed that they showed adaptive programming, with reduced cortisol metabolism via renal 11β-hydroxysteroid dehydrogenase-2 and hepatic 5α-reductase and enhanced tissue responsiveness to corticosteroids.15 Although this modulation in the hypothalamic–pituitary–adrenal axis would have been beneficial during acute starvation and salt depletion, in the longer term it places Holocaust survivors at increased risk of cardiometabolic disease, such as hypertension, diabetes, atherosclerotic heart disease, dyslipidaemia, and vascular dementia. Limitations of this study, however, included reliance on medical chart review for diagnosis of current cardiovascular disease, lack of detail on method of participant recruitment, and imperfect matching of the control population for sex.

The Barker hypothesis has also been implicated in explaining the significantly higher rates of cancers, particularly breast and colorectal cancers, observed in Israeli survivors. An examination of Jewish birth cohorts in 5-year increments from 1920 to 1945 revealed that the incidence of cancer is increased among Holocaust-exposed Jews across all cohorts compared with controls.20,21 The greatest increase was observed in the 1940–1945 birth cohort (a relative risk of 3.50 for all-site cancer among men), among whom there was presumably extreme physiological stress in utero and after birth.

However, this study of 315 544 participants had a major limitation — the inclusion criteria for the “Holocaust-exposed” cohort was only that the participant was Jewish and living in Europe between 1939 and 1945. Therefore, no data were provided on participants’ individual Holocaust experience (ie, concentration camps, ghettos, hiding) or degree of malnutrition at the end of the war.

Doctors in the death camps performed unethical experiments on large numbers of prisoners.22,23 Procedures included incompatible unsterile blood transfusions, injections of toxic substances, and unanaesthetised operations, including abortions and male and female sterilisations.23-26 The effects of these experiments may create late sequelae and new problems decades after the Holocaust. One case study reported that a patient subjected to left intra-testicular injection with an unknown substance in Auschwitz in 1943 developed a secondary giant malignant fibrous histiocytoma of the testis and spermatic cord 53 years later.27