How to Adapt Cognitive-Behavioral Therapy for Older Adults: To Improve Efficacy, Focus on Losses, Transitions, and Changes in Cognition

Abstract

Some older patients with depression, anxiety, or insomnia may be reluctant to turn to pharmacotherapy and may prefer psychotherapeutic treatments. (1) Evidence has established cognitive-behavioral therapy (CBT) as art effective intervention for several psychiatric disorders and CBT should be considered when treating geriatric patients (Table 1). (2) Table 1 Indications for CBT Mild to moderate depression. In the case of severe depression, CBT can be combined with pharmacotherapy Anxiety disorders, mixed anxiety states Insomnia--both primary and comorbid with other medical and/or psychiatric conditions CBT: cognitive-behavioral therapy Research evaluating the efficacy of CBT for depression in older adults was first published in the early 1980s. Since then, research and application of CBT with older adults has expanded to include other psychiatric disorders and researchers have suggested changes to increase the efficacy of CBT for these patients. This article provides: * an overview of CBT's efficacy for older adults with depression, anxiety, and insomnia * modifications to employ when providing CBT to older patients. The cognitive model of CBT In the 1970s, Aaron T. Beck, MD, developed CBT while working with depressed patients. Beck's patients reported thoughts characterized by inaccuracies and distortions in association with their depressed mood. He found these thoughts could be brought to the patient's conscious attention and modified to improve the patient's depression. This finding led to the development of CBT. CBT is based on a cognitive model of the relationship among cognition, emotion, and behavior. Mood and behavior are viewed as determined by a person's perception and interpretation of events, which manifest as a stream of automatically generated thoughts (Figure, page 12). (3) These automatic thoughts have their origins in an underlying network of beliefs or schema. Patients with psychiatric disorders such as anxiety and depression typically have frequent automatic thoughts that characteristically lack validity because they arise from dysfunctional beliefs. The therapeutic process consists of helping the patient become aware of his or her internal stream of thoughts when distressed, and to identify and modify the dysfunctional thoughts. Behavioral techniques are used to bring about functional changes in behavior, regulate emotion, and help the cognitive restructuring process. Modifying the patient's underlying dysfunctional beliefs leads to lasting improvements. In this structured therapy, the therapist and patient work collaboratively to use an approach that features reality testing and experimentation. (4) Indications for CBT in older adults Depression. Among psychotherapies used in older adults, CBT has received the most research for late-life depression. (5) Randomized controlled trials (RCTs) have found CBT is superior to treatment as usual in depressed adults age [greater than or equal to]60. (6) It also has been found to be superior to wait-list control.(7) and talking as control. (6), (8) Metaanalyses have shown above-average effect sizes for CBT in treating late-life depression. (9), (10) A follow-up study found improvement was maintained up to 2 years after CBT, which suggests CBT's impact is likely to be long lasting. (11) Thompson et al (12) compared 102 depressed patients age >60 who were treated with CBT alone, desipramine alone, or a combination of the 2. A combination of medication and CBT worked best for severely depressed patients; CBT alone or a combination of CBT and medication worked best for moderately depressed patients. CBT is an option when treating depressed medically ill older adults. Research indicates that CBT could reduce depression in older patients with Parkinson's disease (13) and chronic obstructive pulmonary disease. (14) As patients get older, cognitive impairment with comorbid depression can make treatment challenging. …