Evidence Based Treatment
of Geriatric Patients
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Gerontology
A Training Resource
By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
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Historical Perspective
Researchers In 2002 after pointing out that at least one in five people over the age of 65 suffers from a mental disorder and that by 2030 the number of persons with psychiatric disorders in this older group will equal or exceed the number with such disorders in younger age groups (age 18 to 29 or age 30 to 44). And concluding that despite the growing requirement for mental health services for older persons, there is substantial unmet need. These researchers concluded that that there is a clear and urgent demographic imperative to address the emerging public health problem of the mental disorders of aging (Bartels, et al., 2002).
In 2007, it was recognized that It cannot be assumed that older adults respond to psychological treatments in the same manner as their younger counterparts. It was around 2007 that there been enough data collected and criteria developed to allow researchers to perform broad reviews of the geropsychology literature to identify specific psychological treatments having the strongest evidence to support their use (Yon & Scogin, 2007). These writers cautioned that not only must the treatment’s merit be considered, but clinicians’ expertise and clients’ values and preferences should be taken into account as well. They concluded that once informed about such treatments, practitioners will have a variety of solid treatments to offer their clients, thus patient choice can be taken into account (Yon & Scogin, 2007).
Major barriers limiting practitioners’ implementation of therapeutic interventions with older adults who live in the community either alone or with caregivers included time restraints, costs, and organizational hindrances. Perceived barriers to implementing interventions on behalf of caregivers also included time restraints and the complexity of new interventions. Because both practitioners and caregivers identified time restraints as key obstacles to implementation, issues such as the length of program training, the frequency of intervention delivery, and the time needed to learn documentation procedures were considered in a 2018 report (Juckett & Robinson, 2018).
In 2019 a study provided the following recommended lifestyle changes which can delay or prevent the onset of Alzheimer’s Disease (AD):
- Higher levels of physical exercise in cognitively intact older adults are linked with reduced brain amyloid beta deposits- Mentally stimulating activities were found to be associated with a reduced risk of developing AD in a cohort of cognitively intact older adults- Random Controlled Treatment studies have found that mindfulness-based interventions can modulate inflammatory processes implicated in AD- The Mediterranean and DASH diets are associated with better cognitive function and slower cognitive decline- Despite some evidence of the benefit of alcohol, non-drinkers should not be advised to begin drinking- A multi-domain approach for lifestyle modification should be strongly recommended to cognitively intact older patients
The final conclusion of this study was to advise patients that pursuing a healthy lifestyle is a key to delaying or preventing Alzheimer’s disease. This involves managing cardiovascular risk factors and a combination of staying physically, mentally, socially, and spiritually active, in addition to adhering to a healthy diet such as the Mediterranean diet (Khoury, Shoch, Nair, Paracha & Grosberg, 2019).
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Dealing with Aging Adults Mental Health Disorders
A report in 2004 found that between 1985 and 2004 there was emerging evidence of efficacious psychosocial interventions for older individuals and their families. They concluded that the most consistent support was found for treatments employing:
1. Cognitive-behavioral focused on dealing with depression and other emotional concerns
2. Problem solving focused on improving activities of daily living
3. Reminiscence therapies which is focused on improved coping, lowering anxiety, lessening depression; increasing life satisfaction and higher well-being (Cummings, Kropf, Cassie & Bride, 2004).
There is a major reciprocal relationship of health problems and depression in older adults. The importance of providing integrated care for physical and mental health problems in the same setting seems unarguably indicated and highly supported by researchers (Skultety & Zeiss, 2006). Thus there is a need for mental health professionals to be located on site in such acute care and assisted living care centers to provide integrated behavioral health services to elderly who have major physical health concerns.
There has been a push to increase the amount of collaborative services with older adults and one model is “The Iowa Model” which reflects a state-of-the-art approach
allowing for a greater range of mental health problems to be identified and treated, facilitates flexibility in staffing and other site-specific operations, requires formal diagnostic assessments, and supports a treatment plan that goes well beyond symptom-specific, time-limited approaches (Kaskie & Buckwalter, 2010).
Psychosocial intervention with adults with anxiety and complicating cognitive limitation were successful in treating such issues as fear of falling, compulsive hoarding, and late-life PTSD using Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), Exposure therapy and Integration of religion and spirituality into CBT (Shrestha, Robertson & Stanley, 2011).
Depression, cardiovascular disease (CVD) risk factors and cognitive impairment are major causes of disability and poor health outcomes in the aging population. Online Cognitive Behavior Therapy over a 12-week intervention resulted in lowering the severity of depressive symptoms with some changes in cognitive function and increase adherence to treatment for their cardiovascular disease (Cookayne, et al., 2011).
An estimated one-third of HIV-positive older adults continues to engage in sexual behaviors that risk HIV transmission or the acquisition of other sexually transmitted infections and that co-morbid depression unless addressed simultaneously negatively impacts positive outcomes for HIV medical intervention (Lovejoy & Heckman, 2014).
IMPACT (Improving Mood—Promoting Access to Collaborative Treatment) has a large body of evidence demonstrating its effectiveness for treating late-life depression in clients enrolled in a clinical research study, but little was known about how well the collaborative care model translates into treatment provided in a public mental health setting and in 2015 it was found that depression severity decreases for 85% of the clients in a public health setting. IMPACT provided older adults with problem solving therapy and antidepressant medications in the public health care setting. Services were delivered by a treatment team consisting of the primary care physician, a consulting psychiatrist, and a depression care specialist (Peukunas & Hahn-Smith, 2015).
In research using Motivational Interviewing to assist older adults with chronic pain follow closely the limitations place on their use of opioids found that participants demonstrated a significantly reduced risk of prescription opioid misuse, decreased substance use, increased self-efficacy, increased motivation to change, and decreased depression (Chang, Compton, Almeter & Fox 2015).
A successful model of destigmatizing the diagnosis of depression used peer education by an older adult with a history of depression currently in recovery who would be paired with an individual recently diagnosed with depression. The “peer in recovery” would provide the “newly diagnosed peer” with psychoeducation, social support and motivational interviewing. Results of the study demonstrated that internalized stigma was significantly reduced after participating in the peer education intervention (Conner, McKinnon, Ward, Reynolds & Brown, 2015). In addition, participants identified 4 mechanisms through which contact with their peer educator impacted their stigmatized beliefs: age related concerns, shared understanding, improved mental health literacy, and mutual support (Conner, McKinnon, Ward, Reynolds & Brown, 2015).
Research demonstrated that older adults with Hoarding Disorder can be engaged in treatment, they often needed to be provided substantial support, including informal motivational interviewing and problem solving, in scheduling and attending the initial visit (Ayers, et al., 2015). Typically, mid-life and older adults with clinically significant hoarding symptoms demonstrate marked indecision, low motivation for change, passive resistance, and seek treatment only at the request of a significant other. However, in this research CBT treatment included motivational interviewing, problem solving, cognitive restructuring, and exposure to discarding with marked success (Ayers, et al., 2015).
‘Complex care’ refers to patients with health care needs that are complicated by significant medical and psychosocial factors, such as multiple chronic conditions and comorbid physical and mental health conditions. One way to address the needs of these patients was the development of programs which augment mental health interventions to address their anxiety, complex conditions, and lack of community support (Ritchie, et al. 2016).
A 12-week manualized group intervention that combined educational, motivational,
medication management skills and symptom management training adapted for older adults show some marked was seen in medication adherence, medication management ability, depressive symptoms, and selected indices of health-related quality of life improvement for the seniors with Bipolar Disorder who participated in this program. (Depp, Lebowitz, Patterson, Laxcro & Juste, 2017)
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Dealing with Late-Life Suicide
Suicide is a tragic, traumatic loss, and one of the most emotionally devastating events families, friends, and communities experience. Suicide claims more than 800,000 lives every year, and some of the highest rates of suicide in the United States and globally are among older adults (Bucher & Ingram, 2018). The first issue is assessment for late life suicide in older adults which involves an interview with the individual which looks at the following factors:
- Identification of risk factors, diagnosed medical problems, medications, functional status, nutritional status, personal and family psychiatric history, alcohol or drug use, thorough physical and neurological examination
- Cognitive functioning mental status examination, including changes in cognition over time; educational level
- Psychological strengths and symptomatology, coping skills, spirituality, sexuality, suicidal ideation, past attempts at suicide
- Quality and quantity of social support, financial status, legal history, potential for elder abuse
- Time course /duration and severity of depressive symptoms to differentiate type of depression (Bucher & Ingram, 2018).
A set of factors which reduce the risk of late-life suicide in older adults were found to be:
- Cultural pride- Positive relationships with friends- Positive religious/spiritual beliefs- Sense of responsibility to family- Positive family relationships- Self-identity and consciousness- Female gender- Married or partnered- Fear of suicide- Greater numbers of children and grandchildren- Recognition of purpose and meaning in life- Social cohesion and pro-social behavior (Bucher & Ingram, 2018).
Finally, the study presented the secondary prevention interventions for late-life suicide risk in older adults:
Crisis intervention to ensure safety is the highest level of secondary prevention. The following measures may be used individually or in combination to prevent suicide attempts. The appropriate measure or combination of measures should be determined by a trained professional. Other measures that focus on longer term secondary prevention are also listed.
Crisis Interventions:
- Hospitalization- Increased surveillance- Partial hospitalization- Day treatment- Antidepressant medications- Communicating risk to family- Appointment of care manager
Other Interventions:
- Care manager for more frequent risk assessment- Counseling: Cognitive-behavioral therapy and Decision-making support- Support groups- Assistance to resolve family discord- Assistance with financial stress- Increase social involvement- Increase activity with faith community (Bucher & Ingram, 2018).
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Working with Aging Adults with Substance Use Disorders & Dual Diagnosis
An innovative geriatric substance abuse program worked at providing both community aging services intervention as well as comorbid substance abuse intervention and was found to be highly successful. It was concluded that programs with both community elder services as well as clinical intervention for substance abuse problems is most effective in working with older adults who have both aging as well as substance abuse issues (D’Augostino, Barry, Blow & Podgorski, 2006).
Agencies in 4 Florida counties (Broward, Pinellas, Sarasota and Orange) conducted screenings (from 2004-2007) among 3497 older adults for alcohol, medications, and illicit substance misuse problems and for depression and suicide risk. Screening occurred in elders’ homes, senior centers, or other selected sites. Individuals who screened positive for substance misuse were offered brief intervention with evidence-based practices and rescreened at discharge from the intervention program and at follow-up interviews (Schonfeld et al., 2010). Prescription medication misuse was the most prevalent substance use problem, followed by alcohol, over-the-counter medications, and illicit substances. Depression was prevalent among those with alcohol and prescription medication problems. Those who received the brief intervention had improvement in alcohol, medication misuse, and depression measures (Schonfeld et al., 2010).
Motivational Interviewing (MI) along and a combination of Motivational Interviewing (MI) and Cognitive Behavior Therapy (CBT) have been demonstrated to effectively assist older adults to reduce their alcohol abuse and convert to a modified moderate use (Kuerbis, Hayes & Morgenstern, 2013). Evidence from existing research on Substance Abuse Treatment for Older Adults suggests that interventions work, yet there is no research to explain conclusively which works best or why. While treatments previously vetted with general population samples, such as Motivational Interviewing (MI), have been utilized with older adults in community practice or adapted for effectiveness Trials there still needs to be more research done to fully explain its effectiveness with older adults (Kuerbis & Sacco, 2013).
Research has demonstrated that to work effectively with older adults who are substance abusers use of a combination of Motivational Interviewing and Cognitive-Behavioral Therapy is effective as long as the clinicians are cross-trained to address frequent mental health co-morbidities and strong relationships with community service providers which enables seamless referrals to physical health providers and other needed services (Cooper, 2012). It has also be demonstrated that primary care settings or health clinic settings offered the most evidence of effective interventions in treating older adults with substance use disorders (Mowbray & Quinn, 2014).
Research demonstrated that Motivational Interviewing was successful intervention with both males and females in sticking to adherence for their dual diagnosed disorders. Also it was suggested that Motivational Interviewing, which seeks to put the client in charge of the content and pace of the session, eschews confrontation, and does not offer explicit directives for change, may not have threatened the male research study participants’ perceived sense of control as much as standard treatment alone and subsequently resulted in increased adherence (Pantalon, Murphy, Barry, Lavery & Swanson, 2014).
Research found that in Continuing Care Residential Communities, residents drank most frequently at home and were alone almost half of drinking days on average, although the context of drinking varied considerably by participant. Problem alcohol use was rare, but hazardous use due to specific comorbidities, symptoms and medications, and the amount of alcohol consumption was common (Sacco, et al., 2015).
In a treatment program using modern telehealth technology found that the use of tablets with face to face 12 weekly educational meetings focused on health living for older adults who were African American Methadone clients found that participants were able to learn how to operate the tablets and enjoyed using the technology. Frequent interactions between the counselors and the participants, using face-to-face video, facilitated success in achieving program goals (Brusoski & Rosen, 2015).
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Treatment of Patients with Mild and Moderate Dementia
Guidelines for the management of diagnosis and treatment of mild to moderate dementia in Canada were published in 2008 (Hogan, et al., 2008). What follows is a summary of their recommendations
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Recommended actions to assist patients with a mild to moderate
dementia and their families after a diagnosis has been made
• Inform the patients and their families (if present and appropriate) of the
diagnosis (this would include general counselling and responding to specific
questions)
• Identify the presence of a family caregivers, what support these people can
offer, their status (i.e., evidence of strain) and their needs (this would include trying to deal with any identified needs) — ongoing activity
• Decide on the need for referrals for further diagnostic and management
assistance (e.g., referral to genetic clinic for suspected familial cases) —
ongoing activity
• Assess for safety risks (e.g., driving, financial management, medication
management, home safety risks that could arise from cooking or smoking,
potentially dangerous behaviors such as wandering) — ongoing activity
• Determine presence of any advance planning documents (e.g., will, enduring
power of attorney, personal directive). If there are no such documents, advise
that they be drafted. Note that this may include assessing the patients’ capacity
to either draft these documents or whether they should be put into effect.
• Assess the patients’ decision-making capacity — ongoing activity
• Provide information and advice about nonpharmacologic and pharmacologic
treatment options and availability of research studies
• Develop and implement treatment plans with defined goals; continually
update plan
• Monitor response to any initiated therapy
• Monitor and manage functional problems (e.g., urinary incontinence) as they
arise
• Assess and manage behavioral and psychological symptoms of dementia as
they arise
• Monitor nutritional status and intervene as needed
• Deal with medical conditions and provide ongoing medical care
• Mobilize community-based and facility-based resources as needed (this
includes being knowledgeable about supportive housing and long-term care
options and the appropriate timing, and process, for facility placement
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Findings from a large, long-term, randomized controlled trial suggested that a multidomain intervention (including diet, exercise, cognitive training and vascular risk monitoring) could improve or maintain cognitive functioning in at-risk elderly people (Nagandu et al., 2015).
The Mediterranean diet has been known to aid in reducing the risk of cardiovascular diseases, cancer and diabetes by a 2017 study was linked to better cognitive function lowering the risk of developing dementia or Alzheimer’s disease in the elderly population (Aridi, Walker & Wright, 2017).
A review of the Evidence-Based Treatments found that they were available, wide ranging and effective for
1.dementia caregivers
2. Anxiety disorders of older adults who are at greater risk of physical illness, falls, depression, disability, early morbidity and mortality, social isolation, and long-term care placement. Evidence Based Treatments for anxiety disorders and anxiety symptoms among older adults have been effectively reduced with CBT and variants of relaxation and meditation methods.
3.Depression in community-dwelling older adults with higher frequency associated with age-related factors such as physical disability, cognitive impairment, and lower socioeconomic status. Evidence Based Treatment for depression symptoms among older adults have been greatly reduced by CBT and reminiscence therapy. psychoeducation, physical exercise, and supportive interventions. (Intrieri, 2016).
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Reminiscence Therapy Helps Seniors with Dementia
(adapted from DailyCaring, 2019)
Reminiscing is when someone shares memories from the past. Typically, with Alzheimer’s and dementia, people lose short-term memory first, but are still able to recall older memories. The goal of reminiscence therapy is to help seniors with dementia feel valued, contented, and peaceful. It can’t reverse or stop the progression of dementia, but the stress reduction and positive feelings can improve your older adult’s mood, reduce agitation, and minimize challenging behaviors like wandering.
Benefits of reminiscence therapy for dementia
Reminiscence therapy can give seniors with dementia a feeling of success and confidence because it’s something they’re still able to do. It gives them an opportunity to talk and share something meaningful rather than just listen. Talking about happy memories of the past also brings joy, which is especially helpful if older adults are having a hard time with everyday life – it helps them cope with stress.
The difference between reminiscing and remembering
Reminiscing is not the same as asking someone to remember something from the past. Remembering something specific, even from long ago, can be stressful for people with dementia because they’re likely to feel pressured or put on the spot. In contrast, when a pleasant memory floats up and they share it with, they’ll feel good. For example, an older adult might not remember right away when asked even a simple question like “Where did you grow up?” But if looking through old photographs with older adults, they might spontaneously say “Oh look, there’s my house. My mom baked my favorite cookies every Saturday – chocolate chip. They were so good.”
What to do if reminiscence brings up painful memories
One never knows which memories will come up when reminiscing about the past. Sometimes a painful or unhappy memory will surface. This isn’t necessarily a bad thing, but it needs to be responded to with kindness and understanding. So if this comes up it is best to listen and offer support so they can feel better by telling the story or if it’s wiser to kindly steer them toward a happier memory so they won’t get stuck in a sad, distressed state.
How to make reminiscence therapy successful
The goal of reminiscence activities is to enjoy time together and set the stage, so seniors have a chance to talk about any memories that come up. For best results, plan for a time of day when they’re most interested in activities, maybe earlier in the day. Choose a quiet, comfortable location where they’ll be able to hear and see the facilitator well. If this older adult doesn’t recall any memories during the activity, that’s 100% OK – maybe nothing came to mind at that moment. The facilitator could offer comments about oneself that might help spark a memory for them (like “This reminds me of going dancing”), but there’s no need to pressure them. With or without reminiscing, they’ll still enjoy these activities.
4 reminiscence therapy activities
Memories can be associated with different parts of the brain, so it’s helpful to try activities that stimulate different senses. This is the time to use one’s imagination and get creative.
1. Listen to their favorite music
Music helps people reminisce and relate to emotions and past experiences. That’s why it’s often recommended for those with Alzheimer’s or dementia. Music can even reach seniors with very advanced dementia. You can play their favorite songs, have a little sing-along, or play music on simple instruments like shakers, bells, tambourines, or a do it yourself drum.
2. Look through photos or keepsakes
Pictures or keepsakes that bring back memories are another excellent way to reminisce. Photos of family, friends, and important life events are always good choices. Photos of things that remind them of favorite hobbies are also great. For example, someone who loves to garden might enjoy looking at a gardening magazine or plant catalog. Someone who loved to cook might like a gourmet magazine with beautiful food photos. The same goes for sports, crafts, historical events, etc.
3. Smell familiar scents and taste favorite foods
Smell is a powerful way to access memories. You could create scent cards or jars with smells that remind them of favorite foods (use spices) or a location like a pine forest near their childhood home (use fresh pine needles or pine scented sticks).
Taste is another way to evoke fond memories. Maybe they always made a special dish for holiday celebrations – the facilitator could make it for them and reminisce while eating together. Or maybe the facilitator could recreate a favorite snack they made for as a treat when their children were young.
4. Enjoy tactile activities like painting, pottery, or other crafts
Touch can also remind someone of the past. Familiar tactile activities like drawing, painting, pottery, knitting, sewing, or other crafts can spark old memories. Even if they can’t participate in these hobbies anymore, doing things like touching paintbrushes, swirling watercolors, scribbling with drawing chalk, squeezing yarn, or playing with fabrics can evoke strong memories. Another way to use touch is through objects. Maybe wearing or handling favorite pieces of jewelry or accessories (like a watch or a necklace) would bring up memories of significant life events. Other ideas would be to bring out a significant piece of clothing (maybe a dress or suit) that they used to love or wear to important events.
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Treatment of Older Adults in Long Term Care Facilities
Older adults who reside in Long Term Care (LTC) facilities have a very high rate of mental health difficulties. Psychologists have been able to provide services to this population through Medicare since the late 1980s, and empirical findings on treatment approaches are important in guiding psychotherapists to more helpful intervention (Powers 2008). The evidence base practices identified at the time by diagnosis were:
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Disorder
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Evidence Based Treatments
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1. Depression
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Problem Solving and Reminiscence Therapies and Cognitive Behavior Therapy (CBT)
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2. Dementia-Related Behavioral Disruption
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Behavioral Interventions/ Applied Behavioral Analysis -Psychoeducation of LTC staff to engage the patients
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3. Anxiety
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Relaxation training, Cognitive Behavioral Therapy and Supportive therapy and Cognitive therapy
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4. Insomnia
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Sleep Restriction/Sleep Compression Therapy and Cognitive Behavior Therapy (CBT)
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5. Nonpharmacological Pain Management
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Cognitive Behavioral Pain Management Program
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(Powers 2008)
An integrated program on the preservation of daily functioning in older people in primary care that consisted of a frailty identification tool and a multicomponent nurse-led care program found that the most frequent self-reported conditions by their patients were loneliness (60.8%) and cognitive problems (59.4%) (Bleijenberg, et al., 2016). Clearly this type of patients’ needs more intense intervention than their settings allow, and further research and experimentation needs to be done to improve older patients’ quality of life.
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Increasing Physical Activity in Aging Adults
A motivational program which involved creation of social network support, motivational support and empowering education for older adults prone to falls, had two components: (1) motivational (motivational support, social network support, empowering education), and (2) fall-reducing physical activities (Physical Activities; guidance to practice leg-strengthening, balance, and flexibility activities and walking). This program was successful in four domains: First, demand was very good, as evidenced by high attendance and low attrition rates. Second, participants evaluated it as acceptable. Third, the intervention was implemented as planned with few exceptions. Finally, the intervention helped 75% of participants to increase their Physical Activity and to improve their functional balance and strength. It also helped participants use community resources (81%) and increase their perceived social support from friends (62%), their readiness (75%), and their self-regulation (75%) for engaging in Physical Activity (McMahon, et al., 2016).
Re-ebablement is an early and time-limited home-based intervention with emphasis on intensive, goal-oriented and interdisciplinary rehabilitation for older adults in need of rehabilitation or at risk of functional decline. Four main themes emerged from these seniors’ experiences of participating in reablement: the first two were intrinsic motivationally oriented 1. “My willpower is needed” 2. ”‘Being with my stuff and my people”. The second two were more extrinsic motivationally oriented 3. “The home-trainers are essential”, and 4. “Training is physical exercises, not every day activities” (Hjelle, Tuntland, Forland, & Alvsvag, 2017). This program demonstrated that it is possible to help seniors remain in their own homes with intensive one on one motivationally supportive intervention.
In the 2018 U.S. Department of Health and Human Services Physical Activity Guidelines for Americans, its key guidelines for adults also apply to older adults they are:
- Adults should move more and sit less throughout the day. Some physical activity is better than none.
- Adults who sit less and do any amount of moderate-to-vigorous physical activity gain some health benefits.- For substantial health benefits, adults should do at least 150 minutes (2 hours and 30 minutes) to 300 minutes (5 hours) a week of moderate-intensity, or 75 minutes (1 hour and 15 minutes) to 150 minutes (2 hours and 30 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Preferably, aerobic activity should be spread throughout the week.- Additional health benefits are gained by engaging in physical activity beyond the equivalent of 300 minutes (5 hours) of moderate-intensity physical activity a week.- Adults should also do muscle-strengthening activities of moderate or greater intensity and that involve all major muscle groups on 2 or more days a week, as these activities provide additional health benefits
In addition to the adult guidelines, the following key guidelines are just for older adults:
- As part of their weekly physical activity, older adults should do multicomponent physical activity that includes balance training as well as aerobic and muscle-strengthening activities.- Older adults should determine their level of effort for physical activity relative to their level of fitness.- Older adults with chronic conditions should understand whether and how their conditions affect their ability to do regular physical activity safely.- When older adults cannot do 150 minutes of moderate-intensity aerobic activity a week because of chronic conditions, they should be as physically active as their abilities and conditions allow (US HHS, 2018)
A 2018 study utilized a 12-week health coaching intervention utilizing Motivational Interviewing and Cognitive Behavior Therapy to help older adults make changes in physical activity and health related outcomes. The results were that the target patients increase moderate to vigorous physical activity during and post intervention. Also, the target patients exhibited healthy changes in body mass, waist size, physical activity self-efficacy, control of type 2 diabetes risk and improved health-related quality of life (Barrett, Begg, O’Halloran & Kingsley, 2018).
A 2019 research project which examined the associations of physical activity, Alzheimer’s Disease and other brain pathologies and cognition in older adults found that higher levels of total daily activity and better motor abilities were independently associated with better cognition (Buchman, et al., 2019)
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Independent vs Supervised Living Conditions for Frail Elderly
In trying to establish evidence-based practices by neuropsychologists working in geriatric rehabilitation settings which serve frail geriatric patients who are over 80 years of age. It was concluded that more research was needed back then (Patrick, Leclerc & Perugini, 2003). The goal of rehabilitation treatment in this population is to help patients maximize their functional independence and regain autonomy to the greatest extent possible to safely resume independent living. They were typically evaluated in these rehabilitation centers post-acute hospitalization for stroke, orthopedic injury, Parkinson’s disease or other functional deconditioning. The discharge goals were to either return home, return home with support services, go to a residential placement or long-term care placement. The majority of these frail patients went home on their own or home with support services at that time (Patrick, Leclerc & Perugini, 2003).
Frailty is an age-related state of decreased physiological reserves characterized by an increased risk of poor clinical outcomes. Evidence supporting the malleability of frailty, its prevention and treatment, was researched in 2018. Results looked for included: 1. cognition, quality of life, activities of daily living, caregiver burden, functional capacity, depression and other mental health-related outcomes, self-perceived health and social engagement; 2. drugs and prescriptions, analytical parameters, adverse outcomes and comorbidities; 3. costs, and/or costs relative to benefits and/or savings associated with implementing the interventions for frailty. The findings were that physical exercise programs were shown to be generally effective for reducing or postponing frailty but only when conducted in groups. Favorable effects on frailty indicators were also observed after the interventions, based on physical exercise with supplementation, supplementation alone, cognitive training and combined treatment (Apostolo, et al., 2018).
Ethical Considerations
The process of capacity assessment is dominated by a fundamental tension between two core ethical principles: autonomy (self-determination) and protection (beneficence). What should clinicians do when an older adult, particularly one who is frail, vulnerable,
dementing, or eccentric, begins to make decisions that put the elder or others in danger, or that are inconsistent with the person’s long-held values? At what point does decision making that is affected by a neuropsychiatric disease process no longer represent ‘‘competent’’ decision making? These are some of the essential, and perplexing, questions of clinical capacity assessment (Moye & Marson, 2007).
The term capacity refers to a dichotomous (yes or no) judgment by a clinician or other professional as to whether an individual can perform a specific task (such as driving or
living independently) or make a specific decision (such as consenting to health care or changing a will). There are at least eight major capacity domains of relevance to older adults with neuropsychiatric illness.
1. Independent living,
2. General financial management and
3. Driving, require a broad set of cognitive and procedural skills and are frequently subject to judicial review.
Other capacities,
4. Treatment consent,
5. Testamentary capacity (wills),
6. Research consent,
7. Sexual consent, and
8. Voting, are generally narrower in scope, focusing on one or a small number of specific decisions requiring an underlying set of cognitive abilities. These narrow capacities, although technically legal capacities, are rarely subject to judicial review (Moye & Marson, 2007).
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Use of Mindfulness Meditation with Aging Adults
2009 Research into telomeres which are the protective caps at the ends of chromosomes with length of telomeres offering insight into mitotic cell and possibly organismal longevity. They reported that mindfulness meditation techniques appear to shift cognitive appraisals from threat to challenge, decrease ruminative thought, and reduce stress arousal and that mindfulness may also directly increase positive arousal states which would have positive effects on telomere length and increasing positive states of mind and hormonal factors that may promote telomere maintenance (Epel, Daubermier, Moskowitz, Folkman & Blackburn, 2009).
An increased need exists to examine factors that protect against age-related cognitive
Decline and there has been preliminary evidence that meditation can improve cognitive function. A 2017 study focused on the standard eight-week mindfulness-based interventions (MBIs) such as mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). The study concluded that eight-week MBI for older adults are feasible but results on cognitive improvement are inconclusive due a limited number of studies, small sample sizes, and a high risk of bias (Berk, van Boxtel & van Os, 2017).
Another study in 2017 found that engaging in mindfulness meditation training improves the maintenance of goal-directed visuospatial attention and may be a useful strategy for counteracting cognitive decline associated with aging (Malinowski, Moore, Mead & Gruber, 2017).
Mindfulness meditation training has been previously shown to enhance behavioral measures of executive control (e.g. attention, working memory, cognitive control) and a study in 2017 demonstrated the regions of the brain impacting executive control were influenced by standardized mindfulness meditation or relaxation training (Taren, et al., 2017).
Mindfulness has assisted aging adults functioning in three arenas 1. behavioral and neural correlates of attentional performance, 2. psychological well-being, and 3. systemic inflammation. A 2017 study on mindfulness training reported that existing evidence points to some improvements in facets of attentional control in older adults and enhancements in both psychological and physical aspects of well-being, and accompanying improvements in systemic inflammation (Zaragoza & Prakash, 2017).
The following summary of the use of Mindfulness-Based Interventions for Chronic pain come from Pain Management - A Neurobiological Approach on coping.us at: http://coping.us/mindfulnessneurobiology/painmanagement.html It is placed here as strong support for older adults who are suffering from chronic or acute pain to be considered good candidates for Mindfulness-Based Interventions.
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Mindfulness-Based Interventions for Chronic Pain
A preliminary Systematic review of the literature in 2011 found that studies up to that date showed that Mindfulness Based Interventions (IBIs) could have nonspecific effects for the reduction of pain symptoms and the improvement of depressive symptoms in patients with chronic pain as well as some improvements in psychologic measures related to chronic pain such as copying with pain following MBIs (Chiesa & Serretti, 2011). In 2017 another meta-analysis of 38 studies found that mindfulness meditation was associated with decrease in pain, reduction of depressive symptoms and increase in quality of life (Hilton, et al., 2017). An analysis of the mechanisms impacted by Mindfulness meditation demonstrated its effectiveness in reducing pain through multiple unique physiological mechanisms (Zeiden & Vago, 2016). Mindfulness was also found to be a useful intervention for the management of post stroke Neuropathic Pain when used independently of other intervention components (Brown & Becerra, 2017)
Ongoing research has supported the benefits of mindfulness intervention on chronic pain (Howarth, et al., 2016; Dunkley & Brotto, 2016; Poulin, et al., 2016; Grazzi, et al., 2017)
There has been a movement to combine Mindfulness not only with Stress Reduction for treating pain but also to combine Mindfulness with both Acceptance and Commitment Therapy (ACT) and Existential Therapy to better focus patient with pain on personal empowerment in the face of unpleasant aspects of the human condition (Harris, 2013). Again, Acceptance and Commitment Therapy (ACT) and Mindfulness were presented as an ideal model for treating chronic pain (McCarcken & Vowles, 2014).
A meta-analytic review of twenty-five Randomly Controlled Studies (RCT totaling 1285 patients with chronic pain, compared acceptance- and mindfulness-based interventions to the waitlist, (medical) treatment-as-usual, and education or support control groups. Outcome measures were pain intensity, depression, anxiety, pain interference, disability and quality of life. ACT showed significantly higher effects on depression and anxiety than MBSR and MBCT (Veehof, Trompetter, Bohlmeijer & Schreurs, 2016). Mindfulness strategies applied in vocational rehabilitation practice settings helped workers with chronic pain achieve job satisfaction, job satisfactoriness, job retention, and high levels of quality of life (Davenport, Koch, Rumrill, 2017)
Strong encouragement has been made to utilize Mindfulness-Based Stress Reduction (MBSR) with patients with chronic pain because it focuses not only on the mind but also the body, it has the potential to address some of the psychosocial factors that are important predictors of poor outcomes (Cherkin, et al., 2014). Also, MBSR was found to contribute positively to pain management by lowering anxiety and depression, feelings of controlling pain and acceptance of higher pain which are important dimensions in patients with long-lasting chronic pain (la Cour & Petersen, 2015). MBSR was also found that patients revealed significant and clinically relevant improvements in level of pain disability, psychological distress, engagement in life activities, willingness to experience pain and subjective ratings of their current pain (Beaulac & Bailly, 2015). Use of MBSR with women with chronic pelvic pain has shown promise in pain reduction (Crisp, Hastings-Tolsma & Jonscher, 2016). Use of MBSR with chronic low pain demonstrated through the measurement of increase in quality of life and decrease in pain severity (Ardito, et al., 2017). MBSR was used with patients with painful diabetic peripheral neuropathy resulting in reduced pain intensity, pain catastrophizing, depression, perceived stress and improved health related quality of life (Nathan, et al.,2017).
In treating Irritable bowel syndrome (IBS) characterized by abdominal pain and hypervigilance to gastrointestinal sensations Mindfulness Treatment appeared to target and ameliorate the underlying pathogenic mechanisms of IBS (Garland, et al, 2012).
Mindfulness-Based Cognitive Therapy (MBCT) and Second Generation Mindfulness Based Intervention (SG-MBI) were both found to reduce the impact of fibromyalgia, its depressive symptoms and intensity of pain (Parra-Delgado & Latorre-Postigo, 2013; Van Gorden, Shonin, Dunn, Garcia-Campayo & Griffiths, 2017).
Participants with chronic pain in a Mindfulness-Oriented Recovery Enhancement (MORE) 8-week program were found after a three month follow up study to have improvement in general activity level and walking ability (Garland, Thomas & Howard, 2014). In working with patients with chronic pain who are opioid seeking would benefit from the MORE process through its cognitive training regimens centered on strengthening attention to natural rewards may remediate reward processing deficits underpinning addictive behavior (Garland, Froeliger & Howard, 2015).
In a systematic review of 23 studies using MBSR and MBCT There was found improved depressive symptoms, anxiety, stress, quality of life and physical functioning. The evidence supports the use of MBSR and MBCT to alleviate symptoms, both mental and physical, in the adjunct treatment of cancer, cardiovascular disease, chronic pain, depression, anxiety disorders and in prevention in healthy adults and children (Gotink, et al., 2015). Pain catastrophizing and psychological distress were identified as individual mediators of the relationship between mindfulness and depressive symptoms for people with chronic pain thus supporting the inclusion of the use of mindfulness based cognitive interventions with these individual (Brooks, et al., 2018).
A Web-based Mindfulness 8-week training program on pain intensity, pain acceptance and life satisfaction was demonstrated as being reasonably successful and open for future research and replication (Henriksson, Wasara & Ronnlund, 2016).
References
Mindfulness-Based Interventions for Chronic Pain
Ardito, R.B., Pirro, P.S., Re, T.S., Bonapace, I., Bruno, E. & Gianotti, L. (2017). Mindfulness-based stress reduction program on chronic low-back pain: A study investigating the impact on endocrine, physical, and psychologic functioning. The Journal of Alternative and Complementary Medicine, 23(8), 615-623. DOI: 10.1089/acm.2016.0423
Beaulac, J. & Bailly, M. (2015). Mindfulness-based stress reduction: Pilot study of a treatment group for patients with chronic pain in a primary care setting. Primary Health Care Research & Development, 16(4), 424-428. DOI: 10.1017/S1463423614000346
Brooks, J.M. Blake, J., Iwanaga, K., Chin, C., Colton, B.P., Morrison, B., Deiches, J. & Chan, F. (2018). Perceived mindfulness and depressive symptoms among people with chronic pain. Journal of Rehabilitation 84 (2), 33-39.
Brown, A. & Becerra, R. (2017). Mindfulness for neuropathic pain: A case study. International Journal of Psychology and Psychological Therapy, 17(1)19-37.
Cherkin, D.C., Serman, K.J., Balderson, B.H., Turner, J.A., Cook, A.J., Stoelb, B., Herman, P.M., Deyo, R.A. & Hawkes, R.J. (2014). Comparison of complementary and alternative medicine with conventional mind-body therapies for chronic back pain: Protocol for the mind-body approaches to pain (MAP) randomized controlled trial. Trials, 15, 211. doi:10.1186/1745-6215-15-211
Chiesa, A. & Serreti, A. (2011). Mindfulness-based interventions for chronic pain: A systematic review of the evidence. The Journal of Alternative and Complementary Medicine, 17(1), 83-89.
Crisp, C.D., Hastings-Tolsma, M. & Jonscher, K.R. (2016). Mindfulness-based stress reduction for military women with chronic pelvic pain: A feasibility study. Military Medicine, 181(9), 982-989.
Davenport, J., Koch, L.C. & Rumrill, P.D. (2017). Mindfulness-based approaches for managing chronic pain: Applications to vocational rehabilitation and employment. Journal of Vocational Rehabilitation 47, 247–258. DOI:10.3233/JVR-170899
Dunkley, C.R. & Brotto, L.A. (2016). Psychological treatments for provoked vestibulodynia: Integration of mindfulness-based and cognitive behavioral therapies. Journal of Clinical Psychology, 72(7), 637-650. DOI: 10.1002/jclp.22286
Garland, E.L., Froeliger, B. & Howard, M.O. (2015). Neurophysiological evidence for remediation of reward processing deficits in chronic pain and opioid misuse following treatment with Mindfulness-Oriented Recovery Enhancement: exploratory ERP findings from a pilot RCT. Journal of Behavioral Medicine, 38, 327-336. DOI 10.1007/s10865-014-9607-0
Garland, E.L. Gaylord, S.A., Palsson, O., Faurot, K., Mann, J.D. & Whitehead, W.F. (2012). Therapeutic mechanisms of a mindfulness-based treatment for IBS: Effects on visceral sensitivity, catastrophizing, and affective processing of pain sensations. Journal of Behavioral Medicine, 35. 591-602. DOI 10.1007/s10865-011-9391-z
Garland, E.L, Thomas, E. & Howard, M.O. (2014). Mindfulness-oriented recovery enhancement ameliorates the impact of pain on self-reported psychological and physical function among opioid-using Chronic pain patients. Journal of Pain and Symptom Management 48(6) 1091-1098.
Gotink, R.A., Chu, P., Busschbach, J.J.V., Benson, H., Fricchione, L. & Hunink, M.G.M. (2015). Standardized mindfulness-based interventions in healthcare: An overview of systematic reviews and meta-analyses of RCTs. PLoS ONE,10(4), 1-17. DOI:10.1371/journal.pone.0124344
Grazzi, L., D’Amico, D., Raggi, A., Leonardi, M., Ciusani, E., Corsini, E, D’Andrea, G., Bolner, A., Salgado-Garcia, F., Andrasik, F. & Sansone, E. (2017). Mindfulness and pharmacological prophylaxis have comparable effect on biomarkers of inflammation and clinical indexes in chronic migraine with medication overuse: Results at 12 months after withdrawal. Neurological Science 38, S173-S175. DOI 10.1007/s10072-017-2874-0
Harris, W. (2013). Mindfulness-based existential therapy: Connecting mindfulness and existential therapy. Journal of Creativity in Mental Health, 8, 349–362. DOI: 10.1080/15401383.2013.844655
Henricksson, J., Wasara, E. & Ronnlund, M. (2016). Effects of eight-week- web-based mindfulness training on pain intensity, pain acceptance, and life satisfaction in individuals with chronic pain. Psychological Reports, 119(3), 586-607. DOI: 10.1177/0033294116675086
Hilton, L., Hempel, S., Ewing, B.A., Apaydin, E., Xenakis, L., Newberry, S., Colaiaco, B., Maher, A.R., Shanman, R. M., Sorbero, M.E. & Maglione, M.A. (2017). Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Annals of Behavioral Medicine, 51, 199-213. DOI 10.1007/s12160-016-9844-2
Howarth, A., Perkins-Porres, L., Smith, J.G., Subramaniam, J., Copland, C., Hurley, M., Beith, I., Riaz, M. & Ussher, M. (2016). Pilot study evaluating a brief mindfulness intervention for those with chronic pain: Study protocol for a randomized controlled trial. Trial, 17, 273. DOI 10.1186/s13063-016-1405-2
La Cour, P. & Petersen, M. (2015). Effects of mindfulness meditation on chronic pain: A randomized controlled trial, Pain Medicine, 16. 641-652.
McCracken, L.M. & Vowles, K.E. (2014). Acceptance and commitment therapy and mindfulness for chronic pain: Model, process and progress. American Psychologist, 69(2), 178-187. DOI: 10.1037/a0035623
Nathan, H.J., Poulin, P., Wozny, D., Taljaard, M., Smyth, C., Gilron, I., Sorisky, A., Lochnan, H. & Shergill, Y. (2017), Randomized trial of the effect of mindfulness-based stress reduction on pain-related disability, pain intensity, health-related quality of life, and A1C in patients with painful diabetic peripheral neuropathy. Clinical Diabetes Journals 35/5/294. DOI: 10.2337/cd17-0077
Parra-Delgado, M. & Latorre-Postigo, J.M. (2013). Effectiveness of mindfulness-based cognitive therapy in the treatment of dibromyalgia: A randomised trial. Cognitive Therapy and Research, 37, 1015-1026. DOI 10.1007/s10608-013-9538-z
Petersen, M. & La Cour, P. (2016). Mindfulness—what works for whom? Referral, feasibility, and user perspectives regarding patients with mixed chronic pain. The Journal of Alternative and Complementary Medicine, 22(4), 298-305. DOI: 10.1089/acm.2015.0310
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Veehof, M.M., Trompetter, H.R., Bohlmeijer, E.T. & Schreurs, K.M.G. (2016). Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review. Cognitive Behaviour Therapy, 45(1), 5-31. http://dx.doi.org/10.1080/16506073.2015.1098724
Van Gorden, W., Shonin, E., Dunn, T.J., Garcia-Campayo, J. & Griffiths, M.D. (2017). Meditation awareness training for the treatment of fibromyalgia syndrome: A randomized controlled trial. British Journal of Health Psychology, 22, 186-206. DOI:10.1111/bjhp.12224
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Recommended Treatment Planning Book for working with Older Adults
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Evidence Based Treatments for a Variety of Disorders
Experienced by Older Adults
The following book is highly recommended for any mental health professional setting out or currently working with older adults. This book covers the following issues with not only Evidence Based Treatment plans but also provides DSM-5 Diagnoses pertinent to each of the designated difficulties.
Frazer, D.W.. Hinrichsen, G.A. & Jongsma, A.E. (2015). The Older Adult Psychotherapy Treatment Planner, with DSM-5 Updates, 2nd Edition (PracticePlanners). John Wiley & Sons, Inc: Hoboken, New Jersey. (You can get this book on Amazon click here)
- Activities of Daily Living
- Anxiety
- Caregiver Distress
- Communication Deficits
- Decisional Incapacity
- Depression
- Disruptive Behaviors in Dementia
- Driving Deficits
- Elder Abuse and Neglect
- Falls
- Interpersonal Dispurte
- Life Role Transition
- Loneliness/Interpersonal deficits
- Mania/Hypomania
- Medical/Medication Issues Unresolved
- Obsessive-Compulsive Disorder (OCD)
- Panic/Agoraphobia
- Paranoid Ideation
- Persistent Pain
- Phobia
- Residential Issues Unresolved
- Sexually Inappropriate Behavior
- Sleep Disturbance
- Somatization
- Spiritual Confusion
- Substance Abuse/Dependence
- Suicidal Ideation
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References Evidence Based Treatment for Geriatric Clients
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Aridi, Y.S., Walker, J.L. & Wright, O.R.L. (2017). The association between the Mediterranean dietary pattern and cognitive health: A systematic review. Nutrients, 9, 674, doi:10.3390/nu9070674
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