Treatment of Older Adults

From the West Coast Geriatric Psychiatry Conference, presented by the University of California, San Diego, School of Medicine, and the Veterans Affairs Center of Excellence for Stress and Mental Health

Educational Objectives

The goal of this program is to improve the psychiatric treatment of older adults. After hearing and assimilating this program, the clinician will be better able to:

1.   Identify anxiety disorders in older adults.

2.   Compare pharmacotherapy and psychotherapy as treatment options for anxiety disorders in older adults.

3.   Cite barriers to the mental health treatment of older adults.

4.   Discuss the characteristics and hallmarks of cognitive behavioral treatment (CBT) and describe common tech­niques used in CBT.

5.   Summarize the empirically supported treatments for posttraumatic stress disorder (PTSD).

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the plan­ning committee to disclose relevant financial relationships within the past 12 months that might create any personal con­flicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Weth­erell receives research support from Forest. Dr. Thorp and the planning committee reported nothing to disclose. In her lecture, Dr. Wetherell discussed the off-label or investigational use of medications.

Acknowledgements

Drs. Wetherell and Thorp were recorded at the West Coast Geriatric Psychiatry Conference, held February 25-28, 2009, in San Diego, CA, and sponsored by the University of California, San Diego, School of Medicine and the Veterans Affairs Center of Excellence for Stress and Mental Health. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Anxiety Disorders in Older Persons

Julie Loebach Wetherell, PhD, Associate Professor of Psychiatry, University of California, San Diego, School of Medicine, La Jolla, and Staff Psychologist, VA San Diego Healthcare System, San Diego, CA

Introduction: prevalence of anxiety disorders »10%; more common in elderly than depression or dementia; general­ized anxiety disorder (GAD) most common anxiety disorder (others include panic disorder [rare in elderly], pho­bias, and posttraumatic stress disorder [PTSD]); anxiety disorders characterized primarily by chronic worry; associated with trouble sleeping; other symptoms may include difficulty concentrating, fatigue, and irritability (especially in men); Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria re­quire that symptoms persist for ³6 mo; most elderly individuals report having had symptoms throughout life (mean duration in surveys 20-30 yr, but 33%-40% experience late onset); consequences include poorer quality of life, increased use of health care services, physical disability, heart disease, and possibly mortality

Anxiety and depression: in primary care setting, anxiety may be seen alone, but in psychiatric settings, usually ac­companied by depression; combination harder to treat than either disorder alone; both chronic and may need treatment over extended periods

Pharmacotherapy for anxiety

GAD: trials in younger adults show efficacy for buspirone, duloxetine, escitalopram, paroxetine, venlafaxine XR, other selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, pregabalin, and antihistamines; fewer studies done with older adults, but those available support efficacy of escitalopram, citalopram, duloxetine, ven­lafaxine, sertraline, pregabalin, and mirtazapine

Other anxiety disorders: only study in geriatric patients used prazocin for PTSD and found it helped with night­mares only; escitalopram shown to be more effective than citalopram for panic attacks

Benzodiazepines: efficacious, but heavily prescribed in older adults; study found higher rate of usage in older adults than in younger adults; in older adults, use associated with increased risk for falls, disability, and cognitive impairment and decline

Escitalopram: trial showed response rate of 69% for escitalopram vs 51% for placebo ( modest clinical signifi­cance)

Adjunctive medication: no formal guidelines for treatment of geriatric anxiety, but benzodiazepines strongly dis­couraged; if benzodiazepine must be used, limit to 6 wk and keep dose low; only 1 study of augmentation with atypical antipsychotic (known to be associated with high mortality risk in older adults with dementia)

Assessment: use objective measure for determining severity of anxiety; consider comorbidity, previous treatment, and cognitive status; obtain medical workup; provide psychoeducation; follow frequently; with any medication, “start low, go slow, but go”

Psychotherapy for anxiety: recent meta-analysis found cognitive behavioral therapy (CBT) more effective than pla­cebo; no data available on psychodynamic compared to mindfulness-based therapies

CBT vs relaxation training (RT): study showed RT alone superior to CBT or CBT with RT

CBT: benefit strongly correlated with amount of homework patient able and willing to do; patient must have intact memory and executive functioning

General recommendations: much psychoeducation needed; family involvement helpful; take slower pace with el­derly than with younger patients; use frequent repetition; provide written material; audiotape each session and have patient listen to tape several times before next session; if using CBT, instruct patient to do homework

Flexible modular patient-centered treatment: speaker finds that concrete ideas tend to be more effective than ab­stract cognitive restructuring in changing behavior in older adults; problem-solving-skills training often helpful; focus on health-related problems often helpful because elderly frequently anxious about real health problems; maintenance therapy necessary (speaker recommends offering 3 “booster sessions” every 6 mo); if psychother­apy not working and patient opposed to taking medications, try motivational interviewing approach

Speaker’s ongoing trial: 2 sessions of psychotherapy; 3 sessions of RT; 3 sessions on problem-solving–skills train­ing; 3 sessions on CBT; try to keep RT and problem-solving cumulative; optional modules offered include ses­sions with family member, sleep hygiene instruction, behavioral activation for patients with comorbid depressive symptoms, and exposure therapy, when indicated

Psychopharmacology vs psychotherapy: not much data on older adults; in trial, medication found to be approxi­mately twice as effective as CBT immediately after treatment and at 6-mo follow-up; recent meta-analyses show no difference between medications and CBT as first-line therapy for geriatric depression, but medications more effective for geriatric anxiety

Sequence: if combined therapy to be used, speaker recommends starting SSRI first because it improves affect and prefrontal functioning, which may help patient focus during CBT; CBT teaches skills that persist; speaker cur­rently has trial in which SSRI started, CBT added, and SSRI gradually discontinued

Conclusions: anxiety common in older adults and has serious health consequences; first-line therapy with medication and CBT appears to be modestly effective; no consensus yet on either as first-line monotherapy; speaker opines that augmentation and maintenance strategies essential, although supporting research as yet unavailable

Cognitive Behavioral Therapy with Older Adults

Steven R. Thorp, PhD, Assistant Professor of Psychiatry, University of California, San Diego, School of Medicine; and Program Director, Posttraumatic Stress Disorders Clinical Team, Veterans Affairs, San Diego Healthcare System, San Di­ego

Barriers to treatment: older adults may be reluctant to seek psychiatric treatment; tend to be noncompliant with medication regimens; often take numerous medications and reluctant to add yet another; primary care physicians do not treat mental health conditions in older adults adequately; ageism in assessment (“of course this person’s de­pressed, they’re old”); providers often neglect to ask about mental health conditions

Treatment preferences: in survey, 79% of older adults reported willingness to try any psychosocial treatment, how­ever, 72% preferred to talk with their primary care provider, while 46% would speak to mental health worker or nurse; only 34% would attend “group therapy”, but 68% would attend “psychoeducational classes”

CBT: most studied and often shown to be most effective psychotherapy in variety of populations; used as umbrella term  covering many different components; “CBT triangle” shows that feelings, thoughts, and behaviors influ­ence each other equally; most presenting complaints related to affect (difficult to influence directly)

Characteristics of CBT: brief and time limited (usually 12 to 20 sessions of 50 to 90 min); involves client-therapist collaboration; structured, with therapist active and directive; therapist uses patient’s thoughts as hypotheses to be questioned and tested; focused on present and on current problems, with little interpretation or source speculation by therapist; involves homework; can be done in individual, couple, family, or group formats

Hallmarks of CBT: set agenda, with specific goals chosen to target within specific number of sessions; addresses problematic thoughts and behaviors and notes how they influence mood and progress toward goals; sessions re­viewed; homework assigned

Common CBT techniques: behavioral activation; scheduling activities; cognitive restructuring; cognitive rehearsal; imaginal exposure and in vivo exposure; role playing and role reversal; addressing therapeutic relationship issues

CBT in mood disorders: depression common in older adults, and prognosis for untreated depression poor;  shortage of mental health providers to meet demands of growing aging population possible, so important for primary care physicians to detect psychiatric disorders and address them with treatment or referral; of psychiatric disorders in elderly, CBT for depression most studied; 75% of older patients studied over 10-yr period showed improvement or remission after 15 to 20 outpatient sessions of CBT, although 30 to 40 sessions more effective for those with chronic or more complex problems; study found that while cognitive strategies worked well for dementia, behav­ioral strategies best for advanced cognitive impairment

Efficacy of CBT for depression: group format effective for older adults; social-problem–solving therapy also works well for older adults; randomized controlled trials show CBT superior to usual care or no treatment, and benefits may be maintained for £3 yr

Depression and Axis II disorders: although clinical lore suggests that Axis II disorders “burn out” in late life, 13% of community-dwelling older adults have personality disorders, and personality disorders often occur with geriat­ric depression; older adults with depression have higher rates of personality disorders than those with other Axis I or with no Axis II disorders; among older adults with depression, one-third have personality disorder, and those with personality disorder less likely to benefit from short-term psychotherapy; study showed that 47% of older adults with depression achieved remission when treated with medication alone; 71% achieved remission when treated with combination of medication and dialectical behavioral therapy (DBT)

Bipolar disorder: little known about bipolar disorder in older adults; study assigned patients with bipolar disorder to collaborative care, or to intensive therapy with CBT, family-focused therapy (FFT), or interpersonal and social rhythm therapy (ISRT); no statistically significant differences between response rates to psychotherapies

CBT and pharmacotherapy: medications for older adults may not work well and are complicated by sensitivity to side effects, dosing issues, potential for harmful interactions with other medications, comorbid medical and neu­rologic disorders, and cost of lifetime use; CBT has yielded effect sizes as large as or larger than pharmacother­apy or other psychotherapies, and patients less likely to relapse; CBT plus medications superior to medications alone

Summary: CBT and DBT effective in improving symptoms and psychosocial outcomes in older adults with depres­sion, less so in those with bipolar disorder; current studies address CBT for improving cognitive compensation skills and medication adherence; newer CBT interventions include mindfulness and acceptance strategies, in ad­dition to more traditional CBT strategies that target changes in thoughts and behaviors

CBT in anxiety disorders: meta-analysis found all studies of older adults focused on GAD or panic disorder, none on obsessive-compulsive disorder or PTSD; treatments more effective than waiting lists or active controls and com­parable to effects in general population; surprise finding of equal or lesser efficacy of CBT compared to that of RT; effect sizes for depressive symptoms in anxious older adults smaller, with no differences among treatment types; interpret results with caution because sample sizes small and control conditions differ

Empirically supported treatments for PTSD: since current wars began, more focus directed to treating effects of trauma; few clinicians ask about trauma; Department of Veterans Affairs identified therapies for PTSD with most empirical support; no controlled trials of psychotherapy for older adults with PTSD; only 5 case studies, with 8 subjects exist

Exposure therapies: prolonged exposure therapies most studied in general population, but concerns expressed about older adults being too frail or not being able to handle exposure therapies (no studies to support these concerns)

Speaker’s pilot study: involved older male veterans with PSTD from military (mostly combat) trauma; objectives to determine feasibility of recruitment of subjects, assessment, and treatment protocol, to characterize population involved, and to assess outcomes; open-label trial of 12 sessions of prolonged exposure therapy; components of therapy include breathing retraining and in vivo and imaginal exposure; primary outcome variable Clinician Ad­ministered PTSD Scale (CAPS); at posttreatment assessment, 75% of subjects no longer met DSM-IV criteria for PTSD

General assessment guidelines: obtain physical examination; request history of work, relationships, and disorders; ask if patient has ever experienced traumatic event; assess social support, cognitive status, and patient’s ability to perform activities of daily living; rather than mood problems, older adults may report appetite, sleep, or cognitive problems; may resist “airing dirty laundry”; often helpful to begin assessment by inquiring about physical com­plaints and lead into mental health issues; all printed materials should use large font in high-contrast print; speak loudly, if necessary; use observation and seek collateral reports in addition to patient’s self-report; eschew psycho­babble, current slang, and other jargon; word questions and suggestions carefully (eg, use “classes” rather than “group therapy”); record sessions and have patient listen to recordings between sessions; use clinical instruments to measure progress; establish strong relationship between therapist and client; provide more practical assistance and concrete recommendations

Summary: need exists for mental health treatment for older adults; older patients often willing to utilize CBT and may benefit from CBT alone or in conjunction with psychopharmacology; presentation and language can encour­age older adults to initiate and continue CBT; assessment and treatment should be multimodal and multifaceted

Suggested reading

Andreescu C et al: Effect of comorbid anxiety on treatment response and relapse risk in late-life depression: controlled study. Br J Psychiatry 190:344, 2007; Areán PA, Cook BL: Psychotherapy and combined psychotherapy/pharmacotherapy for late life depression. Biol Psychiatry 52:293, 2002; Bartels SJ et al: Evidence-based practices in geriatric mental health care. Psychiatr Serv 53:1419, 2002; Beekman AT et al: Anxiety and depression in later life: Co-occurrence and commu­nality of risk factors. Am J Psychiatry 157:89, 2000; Benítez CI et al: Use of benzodiazepines and selective serotonin reup­take inhibitors in middle-aged and older adults with anxiety disorders: a longitudinal and prospective study. Am J Geriatr Psychiatry 16:5, 2008; Cukrowicz KC et al: Personality traits and perceived social support among depressed older adults. Aging Ment Health 12:662, 2008; Kubzansky LD et al: Prospective study of posttraumatic stress disorder symptoms and coronary heart disease in the Normative Aging Study. Arch Gen Psychiatry. 64:109, 2007; Lynch TR et al: Dialectical be­havior therapy for borderline personality disorder. Annu Rev Clin Psychol 3:181, 2007; Miklowitz DJ et al: Intensive psy­chosocial intervention enhances functioning in patients with bipolar depression: results from a 9-month randomized controlled trial. Am J Psychiatry 164:1340, 2007; Smoller JW et al: Panic attacks and risk of incident cardiovascular events among postmenopausal women in the Women’s Health Initiative Observational Study. Arch Gen Psychiatry 64:1153, 2007; Steffens DC, McQuoid DR: Impact of symptoms of generalized anxiety disorder on the course of late-life depres­sion. Am J Geriatr Psychiatry 13:40, 2005; Thorp SR et al: Meta-analysis comparing different behavioral treatments for late-life anxiety. Am J Geriatr Psychiatry 17:105, 2009; Tully PJ et al: Anxiety and depression as risk factors for mortality after coronary artery bypass surgery. J Psychosom Res 64:285, 2008; Wetherell JL et al: Modular psychotherapy for anxi­ety in older primary care patients. Am J Geriatr Psychiatry 17:483, 2009.