Evidence-Based Reviews

How to adapt cognitive-behavioral therapy for older adults

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To improve efficacy, focus on losses, transitions, and changes in cognition



Some older patients with depression, anxiety, or insomnia may be reluctant to turn to pharmacotherapy and may prefer psychotherapeutic treatments.1 Evidence has established cognitive-behavioral therapy (CBT) as an effective intervention for several psychiatric disorders and CBT should be considered when treating geriatric patients (Table 1).2

Table 1

Indications for CBT

Mild to moderate depression. In the case of severe depression, CBT can be combined with pharmacotherapy
Anxiety disorders, mixed anxiety states
Insomnia—both primary and comorbid with other medical and/or psychiatric conditions
CBT: cognitive-behavioral therapy

Research evaluating the efficacy of CBT for depression in older adults was first published in the early 1980s. Since then, research and application of CBT with older adults has expanded to include other psychiatric disorders and researchers have suggested changes to increase the efficacy of CBT for these patients. This article provides:

  • an overview of CBT’s efficacy for older adults with depression, anxiety, and insomnia
  • modifications to employ when providing CBT to older patients.

The cognitive model of CBT

In the 1970s, Aaron T. Beck, MD, developed CBT while working with depressed patients. Beck’s patients reported thoughts characterized by inaccuracies and distortions in association with their depressed mood. He found these thoughts could be brought to the patient’s conscious attention and modified to improve the patient’s depression. This finding led to the development of CBT.

CBT is based on a cognitive model of the relationship among cognition, emotion, and behavior. Mood and behavior are viewed as determined by a person’s perception and interpretation of events, which manifest as a stream of automatically generated thoughts (Figure).3 These automatic thoughts have their origins in an underlying network of beliefs or schema. Patients with psychiatric disorders such as anxiety and depression typically have frequent automatic thoughts that characteristically lack validity because they arise from dysfunctional beliefs. The therapeutic process consists of helping the patient become aware of his or her internal stream of thoughts when distressed, and to identify and modify the dysfunctional thoughts. Behavioral techniques are used to bring about functional changes in behavior, regulate emotion, and help the cognitive restructuring process. Modifying the patient’s underlying dysfunctional beliefs leads to lasting improvements. In this structured therapy, the therapist and patient work collaboratively to use an approach that features reality testing and experimentation.4


The cognitive model of CBT

CBT: cognitive-behavioral therapy
Source: Adapted from reference 3

Indications for CBT in older adults

Depression. Among psychotherapies used in older adults, CBT has received the most research for late-life depression.5 Randomized controlled trials (RCTs) have found CBT is superior to treatment as usual in depressed adults age ≥60.6 It also has been found to be superior to wait-list control7 and talking as control.6,8 Meta-analyses have shown above-average effect sizes for CBT in treating late-life depression.9,10 A follow-up study found improvement was maintained up to 2 years after CBT, which suggests CBT’s impact is likely to be long lasting.11

Thompson et al12 compared 102 depressed patients age >60 who were treated with CBT alone, desipramine alone, or a combination of the 2. A combination of medication and CBT worked best for severely depressed patients; CBT alone or a combination of CBT and medication worked best for moderately depressed patients.

CBT is an option when treating depressed medically ill older adults. Research indicates that CBT could reduce depression in older patients with Parkinson’s disease13 and chronic obstructive pulmonary disease.14

As patients get older, cognitive impairment with comorbid depression can make treatment challenging. Limited research suggests CBT applied in a modified format that involves caregivers and uses problem solving and behavioral strategies can significantly reduce depression in patients with dementia.15

Anxiety. Researchers have examined the efficacy of variants of CBT in treating older adults with anxiety disorders—commonly, generalized anxiety disorder (GAD), panic disorder, agoraphobia, subjective anxiety, or a combination of these illnesses.16,17 Randomized trials have supported CBT’s efficacy for older patients with GAD and mixed anxiety states; gains made in CBT were maintained over a 1-year follow-up.18,19 In a meta-analysis of 15 studies using cognitive and behavioral methods of treating anxiety in older patients, Nordhus and Pallesen16 reported a significant effect size of 0.55. In a 2008 meta-analysis that included only RCTs, CBT was superior to wait-list conditions as well as active control conditions in treating anxious older patients.20

However, some research suggests that CBT for GAD may not be as effective for older adults as it is for younger adults. In a study of CBT for GAD in older adults, Stanley et al19 reported smaller effect sizes compared with CBT for younger adults. Researchers have found relatively few differences between CBT and comparison conditions—supportive psychotherapy or active control conditions—in treating GAD in older adults.21 Modified, more effective formats of CBT for GAD in older adults need to be established.22 Mohlman et al23 supplemented standard CBT for late-life GAD with memory and learning aids—weekly reading assignments, graphing exercises to chart mood ratings, reminder phone calls from therapists, and homework compliance requirement. This approach improved the response rate from 40% to 75%.23

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