Elderly

1
Elderly

• Psychological Assessment
• Treatment and Management

2
Mood Disorders

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

3
Depression in the Elderly

• Symptoms
• 15 community residents gt 65years
• Major depression
• 3 in community
• 5 in primary care clinics
• 25 nursing home residents
• High in chronic medical conditions which limit
  functional abilities

4
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

5
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

6
Therapies

• Anxiety disorders
• Depression
• Grief therapy
• Insomnia
• Family involvement
• Other

7
Treatment of Affective Disorders

• Physical health
• Cognitive decline
• Loss
• Patient expectations
• Therapist expectations
• Rambling

8
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

9
Anxiety

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

10
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.

11
Depression

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

12
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

13
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

14
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

15
Case Example Mr B

• Middle Phase
• Behavioural
• Relaxation exercises
• Identify pleasant events
• Cognitive
• Dysfuntional thoughts record
• Assertiveness training
• Final Phase
• Maintenance guide
• Booster session

16
Pleasant Events Scale
17
Dysfunctional Thought Record
18
Assertive Rights
19
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

20
Thompson et al 1994

• Combination of drugs and psychological therapies
  often used
• Desipramine vs
• CBT (16 - 20 sessions) vs
• Both
• CBT Both gt desipramine

21
Bibliotherapy

• Scogin et al 1990
• J 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

22
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

23
Overviews

• Scogin McElreath 1994
• 17 trials
• 765 participants over 60 years
• Effect size 0.78
• Comparison between therapies showed no advantage
  of any approach

24
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

25
Mood Problems after Stroke

• CBT and chronic illness

26
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

27
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 admissions?111 first stroke
• WDI GHQ28 at one year
• 42 depressed on either measure
• Using same criteria as Wade
• 38 definitely depressed
• 26 probably depressed

28
Psychological Management

• Kneebone Dunmore 2000
• Brit J Clin Psy 39 53-65

29
Pilot Study Lincoln et al 1997

• Stroke patients
• SCED
• 4 weeks baseline
• 10 weeks CBT
• 19 stroke patients 8 - 109 weeks after
  stroke 8.4 sessions CBT (range 3-15)

30
Results

• Significant improvement on BDI (p0.02)
• No significant improvement on WDI (p0.06)
• No significant improvement on HAD-D (p 0.27)

31
Single Case Analyses

• consistent benefits 4
• some benefit 3
• minimal benefit 3
• no benefit 9
• Total 19 patients

32
Discussion

• Results suggested RCT justified
• Clinical Rehabilitation 1997 11 114-122
• RCT
• Lincoln Flannaghan 2003 Stroke

33
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 at 3m 6m
post S.C.A.N
34
Attention Placebo

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

35
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

36
Outcome on Beck Depression Inventory
37
Outcome on GHQ28
38
Discussion

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

39
Is CBT an appropriate strategy?

• 50 stroke patients
• Cognitions significantly related to mood
• CQ with BDI
• rs 0.81 plt0.001
• CQ with WDI
• rs 0.80 plt 0.001

40
Reduction in distress

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

41
Therapies

• Anxiety disorders
• Depression
• Grief therapy
• Insomnia
• Family involvement
• Other

42
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

43
Insomnia

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

44
Family Involvement

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

45
Other problems

• Sexual
• Paranoid delusions
• Problem drinking

46
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.