David Bienenfeld, MD, is with the Department of Psychiatry, Wright State University, Boonshoft School of Medicine, Dayton, Ohio.
Dr. Bienenfeld has disclosed no relevant financial relationships.
Address correspondence to: David Bienenfeld, MD, Department of Psychiatry, Wright State University, Boonshoft School of Medicine, Box 927, Dayton OH 45401-0927; or e-mail firstname.lastname@example.org.
This issue of Psychiatric Annals is predicated on the usefulness and adaptability of various psychotherapies in the growing population of older individuals suffering from a variety of mental disorders. Cognitive behavioral therapy (CBT) is an important member of that class of therapies.
Across demographic and clinical spectra, CBT is the most empirically tested and validated form of psychotherapy. That generalization holds true for the use of CBT in the elderly as well, at least in part because the cognitive model includes no inherent ageist prejudice.1 Studies have unequivocally demonstrated the usefulness of CBT in depressive disorders2,3 and anxiety disorders, including generalized anxiety disorder, panic disorder, and posttraumatic stress disorder.4–6 Additional studies, series, and reports give good reason to trust the efficacy of CBT for older persons with insomnia,7,8 pain,9 and medical disabilities.10 Across numerous applications, CBT has proved to be adaptable and applicable for use in aging patients.
The Cognitive Model
It will be assumed that the reader has a basic familiarity with the model and techniques of cognitive therapy independent of patient age. Judith Beck’s Cognitive Therapy: Basics and Beyond11 is an excellent introduction and resource. We will deal here particularly with those elements of CBT that require or benefit from adaptation to geriatric populations.
The core of the cognitive model of mental distress is that individuals carry a certain set of Core Beliefs (CB), which represents a vulnerability to maladaptive thinking. These CBs are a product of temperament and past history. Maladaptive CBs can become activated by current stressful situations and generate negative Automatic Thoughts (AT). These negative thoughts then yield the emotions, sensations, and behaviors that are the symptoms of current mental distress.11 The essence of this model is just as relevant in late life as it is in early adulthood. Aging, however, contributes additional elements, outlined and tested by Laidlaw, that increase the explanatory power and therapeutic leverage of the classical model.10
Someone who is 75 years old today is not just 50 years older than someone who is 25 years, he/she is also a member of a cohort born a half century earlier. Beliefs are shaped by the sociocultural environment. Today’s elderly were raised in a society that did not encourage public expressions of emotion and painted depression and anxiety with blame and stigma. Independence and survival were admirable goals. Assessment and formulation of the elderly patient require a frank understanding of these cohort effects.
By the time an older person appears for therapy, he/she has invested time, energy, and self-value in one or more social roles. Over the course of adult life, there is often reward for such investment, and a person may reach his/her later years with a strong rooting of his/her sense of self in the role of worker or mother. When such an investment is exclusive of all others, or otherwise leaves little range for adapting to the circumstances of old age, emotional distress is a common result. The cohort effect is present here also, as the current cohort of elders maintains a gender bias concerning proper roles of men (workers, bosses) and women (wives, mothers).
Changing demographics and societal values mean that older individuals spend more time with younger generations than ever before, in increasingly diverse roles. Elders generally value the transmission of tested values, while younger generations seek new ones. The “generation gap” has important personal implications that affect how older persons think and cope.
This variable describes the individual’s own attitudes toward aging. One who believes that disappointment and loss are the inevitable result of aging will be predisposed to hopelessness if such threats do occur and is unlikely to see any sense in attempting therapy for the inevitable.
Even the most politically correct clinician is forced to acknowledge that age and cohort exert powerful effects on an individual’s ability to engage in the process of CBT. A number of adaptations have been proposed and tested to adapt CBT to older patients.
The single, most-consistent finding about cognition and aging is that processing speed decreases from early adulthood on. Older individuals retain their capacity for new learning, but take longer to acquire information and need to do so in multiple ways. They are also more vulnerable to distraction.12 Several modifications in the administration of CBT accommodate these vulnerabilities:1
- Slower pacing of material. The therapist limits the number of new ideas introduced in each session and takes more time introducing new behavioral and cognitive techniques. Therapy often takes longer, and a course of CBT for depression that might take 12 sessions with a younger patient may take 16 to 20 with an older one.
- Memory aids. The use of notebooks, index cards, recordings, and other devices commonly implemented in CBT become even more valuable with older patients.
- Multimodal training. Verbal interventions are more effective when augmented with demonstration and modeling, plus the memory aids just noted.
The social context of aging requires that a given level of activity requires more of an effort. The conditions such as depression and anxiety that lead people to therapy diminish that effort, leading to a vicious cycle of inactivity and emotional distress. As people age, behavior becomes a more important part of mood restitution compared with cognition alone. CBT in later life appropriately pays significant attention to increasing activity levels, even when motivation is poor. Once the older patient attempts to do things, the therapist then has the opportunity to relate activity to feeling, and to process cognitively the resistances to activity and the positive effects of overcoming them.3,10
Older persons may be taken aback by the role of homework in their therapy. It is important to recognize and address difficulties with homework early in the therapy.13 Therapists should introduce assignments in the earliest sessions so that they become an acknowledged part of the process rather than a mysterious add-on. They can explain how homework allows the brief time in therapy to be integrated with the real-world experiences that motivate the therapy in the first place. At all ages, homework creation should be a collaborative process and should derive directly from the problems identified in the session. Goals should be realistic and paced appropriate to the patient’s age and capacities. Modifications may be required to account for limited mobility and resources attendant to the patient’s age. Homework should also be structured as a no-lose proposition; even failure to complete an assignment is an opportunity to learn and adapt.
Gallagher-Thompson has crafted a structure of treatment phases in CBT with older persons that has been widely promulgated and verified.3,10
“Socialize” the patient to the therapy. Although many younger patients need to be socialized to CBT in specific, elders may need to learn about the psychotherapeutic process generically.
Elicit patient’s expectations about treatment. Patients may bring prejudices about old forms of treatment.
Explain the collaborative nature of CBT. Elders may expect the therapist to be the advice-dispensing authority.
Clarify the time-limited nature. This step may be either frightening or reassuring to those who perceive their problems as overwhelming, and their time as short.
Specify that CBT is a here-and-now therapy, not one that deals primarily with past issues. This step gives one license to steer the patient back from the temptation to revive past problems to the detriment of current recovery.
Establish specific and realistic goals. Setting goals requires identifying a limited number of chief complaints. Goals should be specific enough that the patient can measure progress and should take into account the age-imposed limitations of capacity and resources.
This part of the therapy is where most of the “work” is done. The therapist should be working from the beginning on a comprehensive and explanatory formulation that will guide his/her interventions. As noted, interventions should begin with an emphasis on behavioral elements, and then should expand to cognitive restructuring. Although at a slower pace, the therapist introduces the tools used broadly in CBT, including Socratic questioning, daily thought records, and problem-solving techniques.
At all ages, the closing phase of CBT aims at two main goals: preparation for termination and planning for relapse prevention. Termination may be a charged issue for elders because they have usually experienced more losses than younger patients, and the therapeutic relationship may be unprecedented for them in terms of intimacy and candor. It is often advisable to space out the closing sessions, encouraging self-therapy sessions to encourage independent problem management. Scheduling “booster” and follow-up sessions leaves terminating patients with a sense of continuity and hope.
Formulating the task of relapse prevention allows the patient to approach termination as a constructive task, not just a loss. Patient and therapist may create a “survival guide” of notes and resources gleaned over the course of therapy. The patient then leaves with a sense of having accumulated a set of tools, and with reason to be less fearful of the future.
Cognitive Therapy for Specific Conditions
The clinical indications for CBT are broad, and age alone does not narrow the list. The structure and techniques are mostly the same regardless of age, but there are certain emphases and alterations useful in older patients.
The deficits in memory and processing noted above are exaggerated in depression. Accordingly, even more attention needs to be paid in depressed elders to those technical modifications aimed at adapting to such problems. Slower pace, multimodal instruction, and memory aids become even more important.
Also, the particular effects of depression on concentration, retention, and processing argue for the behavioral emphasis advised above. CBT for depression usually involves measures aimed at increasing actual activity. The therapist needs to be particularly alert to age-related issues in sensation, strength, and mobility, being careful not to assign a homework activity that exceeds the patient’s capacities and risks failure.2
The 11 Depression Inventory-II, the most widely used instrument for screening and for monitoring therapeutic progress in CBT for depression, has been validated in older adults and can be used with confidence. Alternative instruments, validated for the elderly, include the Geriatric Depression Scale and the Center for Epidemiologic Studies-Depression (CES-D).10
Suicide is a particular concern in elders. In the United States, the risk of death by suicide is about 50% higher for those older than 60 years than for the population as a whole.14 From the vantage point of the cognitive model, suicide is strongly linked to hopelessness; in an important study, older persons who scored nine or higher on the 11 Hopelessness scale were 14 times more likely to commit suicide than those who scored less than nine. The clinician should first be aware of the high risk of suicide in depressed elders and should specifically inquire about such thoughts. Of course, grave and imminent risk may call for hospitalization, but more commonly such ideation is chronic and persistent. The therapist should:15
Develop a safety plan. Such a plan helps the patient to regain a sense of control and to experience the salutary effects of effective problem solving. Elements may include distraction and identification of helpful resources.
Formulate the patient’s case around the issue of hopelessness, and identify the links among events, hopeless thoughts, and suicidal feelings. This formulation then dictates targeting hopelessness and increasing problem-solving skills.
Actively help the patient identify and implement reasons for living. Some therapists guide the patient in assembling a collection of mementos that serve as reminders of times when they felt more useful.
Focus actively on termination. Suicide prevention becomes the central element of relapse prevention.
Anxiety and Anxiety Disorders
Wells16 has elaborated on the centrality of worry in anxiety, especially in Generalized Anxiety Disorder (GAD) and usefully distinguished between type-1 worries (worries about particular situations) and type-2 worry (“worry about worry”). Elders with anxiety are more likely than younger cohorts to suffer from type-2 worries and to be preoccupied with worry about the consequences of ceaseless worrying. This formulation improves the productivity of CBT by turning the focus from thoughts about situations to thoughts about worry. Besides standard means of cognitive restructuring, a number of techniques are useful for worry and GAD in the elderly:4,10
- Progressive muscle relaxation (PMR) is easy to learn and can be integrated with most cognitive interventions. Older persons may have unrealistic concerns about engaging in such techniques, and the therapist should inquire about such fears before beginning instruction. Indeed, PMR may be unrealistically difficult for people suffering from arthritis, and might be unsafe in some persons with postural difficulties or cerebrovascular insufficiency.
- Thought stopping is a deliberate strategy to recognize the beginning of a cycle of worry, then acting to halt it. The patient may be instructed to say, “Stop!” out loud. They may carry a card with alternative thoughts to which they then direct their attention instead.
- Worry time may be specifically designated. Long-practiced habits of worry die hard, and the patient may actually experience some sense of control or feel better after having worried a little. Patient and therapist can assign a specific half hour of “worry time,” with a preselected positive activity to follow immediately.
- The Beck Anxiety Inventory (BAI) is as specific and sensitive in older adults as it is in the general population and can be used to monitor treatment progress.
The cognitive model of panic maintains that some individuals perceive normal body sensations in a catastrophic fashion. This misperception snowballs, as fear of the sensation often exaggerates it and makes the mind more sensitive to it. Older adults are often hyperaware of bodily sensations as they fear age-related deterioration. The therapist is advised to begin with a thorough assessment of the somatic sensations during and preceding panic attacks, solidifying the partnership with the patient, and clarifying the somatic phenomena that will be tracked in the therapy. Only then can the emotions and thoughts be elucidated and restructured. Attention should be paid to the “safety behaviors” in which panic sufferers engage to minimize their perceived risk of catastrophe. These must also be addressed with all the instruments of CBT.5,10
Posttraumatic stress disorder (PTSD) takes different shapes in later life. With increasing age, people are less likely to be victims to, or observers of, natural disasters or episodes of extreme violence. But they are more likely to experience loss of spouse, difficult medical treatments such as chemotherapy, and even chronic health problems, as subjectively traumatic experiences. Further, delayed PTSD can emerge as prisoners of war or Holocaust survivors who have been well adjusted for decades are placed in long-term care facilities, re-evoking long-suppressed memories. The majority of those with chronic PTSD had some psychiatric comorbidity such as panic or substance abuse, and treatment of such conditions is mandatory for the effectiveness of CBT. Cognitive restructuring addresses the differentiation of contemporary events from pathogenic trauma and identifies patterns of habituated anxiety. Treatment aims at increasing mastery, constructing a coherent narrative of trauma, and emphasis on positive core memories.6
Age exerts many negative effects on sleep. Although total 24-hour sleep time is usually unchanged, it becomes broken up into segments of fewer hours and more naps. Total REM sleep and deep stage 3 and stage 4 (delta) sleep diminishes. Subjective sleep quality declines with age. CBT for late life insomnia includes education and reinforcement of behavioral sleep hygiene and cognitive restructuring of maladaptive attitudes about sleep.7,8,10
Sleep hygiene includes instructing the patient:
Use the bed only for sleep and sex, not for entertainment, phone calls, etc.
Go to bed only when sleepy.
If unable to fall asleep within 15 to 20 minutes, get out of bed and go to another room. Do something restful until sleepy, then try again.
Repeat steps 1 through 3 as often as necessary.
Use the alarm to get up at the same time every day regardless of time slept or the coming day’s schedule.
Use progressive muscle relaxation to aid sleep.
Cognitive restructuring includes addressing catastrophic expectations of current sleep problems, misperceptions that quantity and quality of sleep are out of one’s control, and erroneous appraisals of the quantity and quality of one’s sleep.
- Zeiss AM, Steffen A. Behavioral and cognitive-behavioral treatments: an overview of social learning. In: Zarit SH, Knight BG, ed. A Guide to Psychotherapy and Aging. Washington, DC: American Psychological Association; 1996:35–59.
- Moss KS, Scogin FR. Behavioral and cognitive treatments for geriatric depression: An evidence-based perspective. In: Gallagher-Thompson D, Steffen AM, Thompson LW, eds. Handbook of Behavioral and Cognitive Therapies with Older Adults. New York, NY: Springer; 2008:1–17.
- Gallagher-Thompson D, Thompson LW. Applying cognitive-behavioral therapy to the psychological problems of later life. In: Zarit SH, Knight BG, eds. A Guide to Psychotherapy and Aging. Washington, DC: American Psychological Association; 1996:61–82.
- Ladouceur R, Leger E, Dugas M, Freeston MH. Cognitive-behavioral treatment of generalized anxiety disorder (GAD) for older adults. Int Psychogeriatr. 2004;16(2):195–207. doi:10.1017/S1041610204000274 [CrossRef]
- Clark DM. Anxiety disorders: why they persist and how to treat them. Behav Res Ther. 1999;37(Suppl 1):S5–S27.
- Hyer L, Sacks A. PTSD (post-traumatic stress disorder) in later life. In: Gallagher-Thompson D, Steffen AM, Thompson LW, ed. Handbook of Behavioral and Cognitive Therapies with Older Adults. New York, NY: Springer; 2008:278–293.
- Sivertsen B, Omvik S, Pallesen S, et al. Cognitive behavioral therapy vs. zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006;295(24):2851–2858. doi:10.1001/jama.295.24.2851 [CrossRef]
- Stone KC, Booth AK, Lichstein KL. Cognitive-behavioral therapy for late-life insomnia. In: Gallagher-Thompson D, Steffen AM, Thompson LW, eds. Handbook of Behavioral and Cognitive Therapies with Older Adults. New York, NY: Springer; 2008:48–60.
- Clifford PA, Cipher DJ, Roper KD, Snow AL, Molinari V. Cognitive-behavioral pain management interventions for long-term care residents with physical and cognitive disabilities. In: Gallagher-Thompson D, Steffen AM, Thompson LW, eds. Handbook of Behavioral and Cognitive Therapies with Older Adults. New York, NY: Springer; 2008:76–101.
- Laidlaw K, Thompson LW, Dick-Siskin L, Gallagher-Thompson D. Cognitive Behaviour Therapy with Older People. Chichester, England; JC Wiley & Sons Ltd: 2003.
- Beck JS. Cognitive Therapy: Basics and Beyond. New York, NY; Guilford Press: 1995:1–24,105–136,248–268.
- Bienenfeld D. Late life. In: Tasman A, Kay J, Lieberman JA, eds. Psychiatry. 3rd ed. Chichester, England: John Wiley & Sons; 2008:196–202.
- Coon DW, Gallagher-Thompson D. Encouraging homework completion among older adults in therapy. J Clin Psychol. 2002;58(5):549–563. doi:10.1002/jclp.10032 [CrossRef]
- Centers for Disease Control and Prevention (CDC). Increases in age-group-specific injury mortality — United States, 1999–2004. MMWR Morb Mortal Wkly Rep. 2007;56(49);1281–1284.
- Brown GK, Brown LM, Bhar SS, Beck AT. Cognitive therapy for suicidal older adults. In: Gallagher-Thompson D, Steffen AM, Thompson LW, eds. Handbook of Behavioral and Cognitive Therapies with Older Adults. New York, NY: Springer; 2008:135–150.
- Wells A. Generalised anxiety disorder. In: Wells A.Cognitive Therapy of Anxiety Disorders. Chichester, England: JC Wiley & Sons; 1997:200–235.