Elderly Psychological Assessment Treatment and Management

Mood Disorders Depression severe in 4% over 65s mild in 13% over 65s Anxiety 3% generalised anxiety 10% phobic disorders

Depression in the Elderly Symptoms 15% community residents > 65years Major depression 3% in community 5% in primary care clinics 25% nursing home residents High in chronic medical conditions which limit functional abilities

Recovery from Depression Livingston & Hinchcliffe % remain depressed 3 years later Only 20% make complete recovery Burvill % complete recovery over a year 18% recover & relapse 24% remain depressed 11% died

Drug treatments available but problems in long term use relapse rates high many do not recover completely 10% do not improve at all Scope for psychological treatments

Therapies Anxiety disorders Depression Grief therapy Insomnia Family involvement Other

Treatment of Affective Disorders Physical health Cognitive decline Loss Patient expectations Therapist expectations Rambling

Anxiety Disorders Sullivan et al % on medication 60% of these still were 3 years later Morgan 1987 sleep disorders 20% men 30% women over 70 reported trouble with sleeping

Anxiety Specific fears Falling Crime Dying Graded exposure PTSD Robbins (1994) 16% veterans WW2 Speed et al (1989) 29% POW Debriefing

King and Barrowclough 1991 Cognitive behavioural intervention in 10 community patients with anxiety disorders Treatment assisting person to reinterpret anxiety symptoms eg not life threatening but benign hyperventilation provocation tests 9/10 improved and this was maintained to month follow up.

Depression CBT Interaction behaviour, cognitions and emotions Strategies to challenge and replace negative automatic thoughts Relationship activity and mood Reintroduction pleasant activities

Case Example Mr B 74 male retired architect Caring for wife with emphysema Sons married and lived away Anxiety and depression as a result of caring for wife Committed to caring for wife Anxious when she is demanding and hostile Ongoing difficulties since wifes health began to decline

Case Example Mr B No previous depression BDI score 20 HRS 18 Contract for 20 sessions CBT Concerned about wifes reaction to his involvement in therapy

Case Example Mr B Early phase Difficult to attend therapy Relaxation at beginning of session Practice relaxation at home Aim To understand and challenge stressful beliefs Increase pleasant, social activities Reduce anxiety when needed to be assertive with wife

Case Example Mr B Middle Phase Behavioural Relaxation exercises Identify pleasant events Cognitive Dysfuntional thoughts record Assertiveness training Final Phase Maintenance guide Booster session

Pleasant Events Scale

Dysfunctional Thought Record

Assertive Rights

Thompson et al 1987 J Consult Clin Psychol 55: cognitive therapy vs behaviour therapy vs brief psychotherapy vs waiting list no sig. diffs in treatment groups 52% moved out of depressed range 18% substantial improvement At 2 year follow-up 70% not depressed

Thompson et al 1994 Combination of drugs and psychological therapies = often used Desipramine vs CBT ( sessions) vs Both CBT = Both > desipramine

Bibliotherapy Scogin et al 1990 J Consult Clin Psychol 57: Mildly and moderately depressed elderly people Bibliotherapy based on cognitive or behavioural approaches vs waiting list control Both self-help books reduced depression, on Hamilton scale and self-report measure, compared to controls 2/3 showed clinically significant change Gains maintained at 2 year follow-up

Group Therapies Steuer et al 1984 Psychodynamic = CBT group therapy 40% drop out during therapy Of those who completed 9 months therapy 40% in remission 40% symptom reduction Ong et al 1987 Weekly support group 7/10 controls rereferred to hospital 0/10 intervention group rereferred

Overviews Scogin & McElreath trials 765 participants over 60 years Effect size 0.78 Comparison between therapies showed no advantage of any approach

but which patients benefit most and least? lack of differences because all encourage increased self- efficacy? how do psychological therapies compare with drug therapies? sleep disorders a major problem group work for relapse prevention

Mood Problems after Stroke CBT and chronic illness

Mood Problems Depressed 30-40% independent of time since stroke Robinson et al /164 consecutively admitted 27% major depression 20% minor depression 9% unduly cheerful

Mood Problems Wade et al acute strokes from 96 GPs Definitely or probably depressed 33% at 3 weeks 32% at 3 months 31% at 6 months Collen et al admissions111 first stroke WDI & GHQ28 at one year 42% depressed on either measure Using same criteria as Wade 38% definitely depressed 26% probably depressed

Psychological Management Kneebone & Dunmore 2000 Brit J Clin Psy 39; 53-65

Pilot Study Lincoln et al 1997 Stroke patients SCED 4 weeks baseline 10 weeks CBT 19 stroke patients weeks after stroke 8.4 sessions CBT (range 3-15)

Results Significant improvement on BDI (p=0.02) No significant improvement on WDI (p=0.06) No significant improvement on HAD- D (p= 0.27)

Single Case Analyses consistent benefits 4 some benefit3 minimal benefit3 no benefit9 Total19 patients

Discussion Results suggested RCT justified Clinical Rehabilitation 1997; 11: RCT Lincoln & Flannaghan 2003 Stroke

Patients on a stroke register screened using BDI & WDI at 1m 3m & 6m S.C.A.N RANDOMISATION PLACEBOTREATMENTCONTROL Visited by Blind Independent Assessor at 3m & 6m post S.C.A.N

Attention Placebo general conversation discussing problems no strategies suggested no advice to carers or hospital staff 10 sessions in 3 months

Cognitive Behaviour Therapy based on manual produced for pilot study delivered by trained experienced therapist advice to carers and hospital staff 10 sessions in 3 months

Outcome on Beck Depression Inventory

Outcome on GHQ28

Discussion Patients were not seeking help High co-morbidity Early intervention if recruited at one month

Is CBT an appropriate strategy? 50 stroke patients Cognitions significantly related to mood CQ with BDI r s 0.81 p<0.001 CQ with WDI r s 0.80 p< 0.001

Reduction in distress Significant problem Limited evidence for effectiveness Multi-component packages Depends on nature of routine care already provided Measurement Problems

Therapies Anxiety disorders Depression Grief therapy Insomnia Family involvement Other

Grief Therapy Most elderly experience many losses Many bereaved, including elderly do not experience depression after the loss Initial reaction stable over next few years Depressed mourners may be depressed prior to death or have long standing difficulty coping with stressful events Need to differentiate hopelessness and helplessness from realistic appraisal

Insomnia Prevalence increases with age Treatment Sleep health education Stimulus control Relaxation Cognitive

Family Involvement Family therapy Marital relationships Siblings and spouses Intergenerational problems Methods Information Advice Life review Genogram

Other problems Sexual Paranoid delusions Problem drinking

Background Reading Lindsey, S.J.E. & Powell, G.E. 1994The Handbook of Adult Clinical Psychology. Routledge Chapters 21 and 22 Woods, R.T. Handbook of the Clinical Psychology of Ageing. Wiley Woods, R.T. Psychological Therapies and their efficacy. Reviews in Clinical Gerontology, 1992, 2, Morris, R.G. & Morris L.W. Cognitive and behavioural approaches with the depressed elderly. Int. Journal of Geriatric Psychiatry, 1991, 6,