Elderly

Psychological Assessment

Treatment and Management

Mood Disorders

Depression severe in 4% over 65’s mild in 13% over 65’s

Anxiety 3% generalised anxiety 10% phobic disorders

Depression in the Elderly

Symptoms 15% community residents > 65yearsMajor depression

3% in community5% in primary care clinics25% nursing home residents

High in chronic medical conditions which limit functional abilities

Recovery from Depression Livingston & Hinchcliffe 1993

33% remain depressed 3 years later Only 20% make complete recovery

Burvill 1993 47% 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 healthCognitive declineLossPatient expectationsTherapist expectationsRambling

Anxiety Disorders Sullivan et al 1988

13% 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 3 - 6 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 wife’s health

began to decline

Case Example Mr B No previous depression BDI score 20 HRS 18 Contract for 20 sessions CBT Concerned about wife’s 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: 385-90

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 (16 - 20 sessions) vs BothCBT = Both > desipramine

BibliotherapyScogin et al 1990J Consult Clin Psychol 57: 403-407 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 1994

17 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 1983 103/164 consecutively admitted

• 27% major depression• 20% minor depression• 9% unduly cheerful

Mood Problems Wade et al 1987

976 acute strokes from 96 GPs Definitely or probably depressed

• 33% at 3 weeks• 32% at 3 months• 31% at 6 months

Collen et al 1987 500 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

8 - 109 weeks after stroke8.4 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 4some benefit 3minimal benefit 3no benefit 9

Total 19 patients

Discussion

Results suggested RCT justified Clinical Rehabilitation 1997; 11:

114-122

RCT Lincoln & Flannaghan 2003 Stroke

Patients on a stroke register screened using BDI & WDI at 1m 3m & 6m

S.C.A.N

RANDOMISATION

PLACEBO TREATMENT CONTROL

Visited by Blind Independent Assessor at3m & 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

TIME

3.002.001.00

Me

an

BD

I to

tal s

core

20

19

18

17

16

15

14

13

group

no intervention

attention placebo

CBT

Outcome on GHQ28

TIME

3.002.001.00

Me

an

GH

Q2

8 s

core

36

34

32

30

28

26

24

22

group

no intervention

attention placebo

CBT

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

rs 0.81 p<0.001 CQ with WDI

rs 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. 1994 The Handbook

of Adult Clinical Psychology. Routledge Chapters 21 and 22

• Woods, R.T. Handbook of the Clinical Psychology of Ageing. Wiley 1996.

• Woods, R.T. Psychological Therapies and their efficacy. Reviews in Clinical Gerontology, 1992, 2, 171-183.

• Morris, R.G. & Morris L.W. Cognitive and behavioural approaches with the depressed elderly.Int. Journal of Geriatric Psychiatry, 1991, 6, 407-413.