Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 90

Psychological Interventions are effective in the elderly with behavioural and mental health disorders, and it appears the older adult population prefers psychotherapy to psychiatric medications (Areán, Alvidrez, Barrera, Robinson, & Hicks, 2002). However, in a survey of physicians, only 27% of respondents indicated they would refer depressed older patients to psychotherapy (Alvidrez & Areán, 2002). Tailoring psychotherapeutic intervention for older adults is often beneficial given comorbid medical complexities and the bidirectional relationship of mental health diagnoses with medical burden, disability, and cognitive impairment. In a review of psychotherapy in older adults, Raue and colleagues show there is evidence that cognitive behavioral therapy (CBT), problem‐solving therapy (PST), and interpersonal psychotherapy (IPT) are similarly effective for treating late‐life depression relative to depression in younger adults (Raue, McGovern, Kiosses, & Sirey, 2017). CBT has been utilized with demonstrated effectiveness in treating late‐life depression and anxiety as well as in those with comorbid depression and heart failure (Freedland, Carney, Rich, Steinmeyer, & Rubin, 2015) or Parkinson’s disease (Calleo, et al., 2015). Providing effective and appropriate psychological intervention can improve the primary psychiatric condition and may positively impact the severity of comorbid medical conditions and healthcare utilization. In a randomized controlled trial for the treatment of depression in heart failure, those receiving CBT versus treatment as usual demonstrated lower depression severity with higher depression remission rates and fewer hospitalizations at six‐month follow‐up (Freedland, et al., 2015). Even in the setting of acute medical illness, CBT for late‐life depression has been found effective in reducing depression symptoms and improving physical functioning at four‐month follow‐up relative to waitlist controls (Hummel, et al., 2017).

Several therapies have been adapted for specific patient populations to address the presentation of depression with comorbid medical conditions. For example, Personalized Adherence Intervention for Depression with Severe COPD (PID‐C) was developed to address depression in COPD with a course of nine sessions (Sirey, Raue, & Alexopoulos, 2007; Alexopoulos, et al., 2013; Alexopoulos, et al., 2016). This intervention focuses on identifying treatment (medical, rehabilitation, psychiatric) adherence barriers and using targeted strategies involving psychoeducation and support to address and overcome those barriers. Randomized controlled trials of PID‐C, as well as the incorporation of PID‐C with PST, resulted in higher remission rates of depressive symptoms and dyspnea‐related disability compared to those receiving treatment as usual. In a systematic review of CBT therapies for older adults with depression and cognitive impairment, PST was found to significantly improve mood and overall disability (Simon, Cordás, & Bottino, 2015). Problem adaptation therapy (PATH) is another therapy modality with empirical support for treating depression in patients with more significant cognitive impairment (Kiosses, et al., 2015). The PATH intervention is delivered in the patient’s home over a 12‐week course, focusing on emotion regulation and reducing negative emotions associated with functional and cognitive limitations.

More generally, a behavioural conceptualization of depression in older adults with dementia can be utilized to appreciate the impact of cognitive impairment on the ability to engage in fulfilling aspects of life and the resultant increases in isolation and social withdrawal. With increased isolation and reduced opportunities for joyful activities, the individual may become more despondent or anxious. Ultimately the elevated psychiatric symptoms serve as an additional barrier to engaging in positive activities, resulting in continued isolation and worsening psychiatric status. Behavioural interventions are strategies used to disrupt that cycle by identifying and reinforcing behaviour associated with positive mood and changing the caregiver–care recipient relationship to reinforce and maintain those positive behaviours (Logsdon, McCurry, & Teri, 2007). In individuals with significant cognitive impairment with or without behavioural disturbance, behavioural interventions may be as basic as maintaining a routine (e.g. consistent bedtime and waking hours) to limit day/night confusion, or they may be more complex and require integration of observed disturbances with the person’s life history. McConnell (2014) provides a case example of utilizing behavioural intervention in a patient with moderate dementia who began to experience sleep disturbance and agitation after placement of devices on his feet to prevent pressure ulcers. The disturbed behaviour was incorporated with the patient’s history of having been a prisoner of war; the medical devices, although intended to help the patient, may have been a trigger for feelings of confinement that led to agitation. As such, disrupting that negative cycle required eliminating the behaviour reinforcer (devices on the patient’s feet) and utilizing a more patient‐appropriate approach (pillows at the end of the bed), which resulted in a reduction of the problematic behaviour.