How to adapt cognitive-behavioral therapy for older adults
To improve efficacy, focus on losses, transitions, and changes in cognition
Insomnia. Studies have found CBT to be an effective means of treating insomnia in geriatric patients. Although sleep problems occur more frequently among older patients, only 15% of chronic insomnia patients receive treatment; psychotherapy rarely is used.24 CBT for insomnia (CBT-I) should be considered for older adults because managing insomnia with medications may be problematic and these patients may prefer nonpharmacologic treatment.2 CBT-I typically incorporates cognitive strategies with established behavioral techniques, including sleep hygiene education, cognitive restructuring, relaxation training, stimulus control, and/or sleep restriction. The CBT-I multicomponent treatment package meets all criteria to be considered an evidence-based treatment for late-life insomnia.25
RCTs have reported significant improvements in late-life insomnia with CBT-I.26,27 Reviews and meta-analyses have also concluded that cognitive-behavioral treatments are effective for treating insomnia in older adults.25,28 Most insomnia cases in geriatric patients are reported to occur secondary to other medical or psychiatric conditions that are judged as causing the insomnia.25 In these cases, direct treatment of the insomnia usually is delayed or omitted.28 Studies evaluating the efficacy of CBT packages for treating insomnia occurring in conjunction with other medical or psychiatric illnesses have reported significant improvement of insomnia.28,29 Because insomnia frequently occurs in older patients with medical illnesses and psychiatric disorders, CBT-I could be beneficial for such patients.
Good candidates for CBT
Clinical experience indicates that older adults in relatively good health with no significant cognitive decline are good candidates for CBT. These patients tend to comply with their assignments, are interested in applying the learned strategies, and are motivated to read self-help books. CBT’s structured, goal-oriented approach makes it a short-term treatment, which makes it cost effective. Insomnia patients may improve after 6 to 8 CBT-I sessions and patients with anxiety or depression may need to undergo 15 to 20 CBT sessions. Patients age ≥65 have basic Medicare coverage that includes mental health care and psychotherapy.
There are no absolute contraindications for CBT, but the greater the cognitive impairment, the less the patient will benefit from CBT (Table 2). Similarly, severe depression and anxiety might make it difficult for patients to participate meaningfully, although CBT may be incorporated gradually as patients improve with medication. Severe medical illnesses and sensory losses such as visual and hearing loss would make it difficult to carry out CBT effectively.
Table 2
Contraindications for CBT
| High levels of cognitive impairment |
| Severe depression with psychotic features |
| Severe anxiety with high levels of agitation |
| Severe medical illness |
| Sensory losses |
| CBT: cognitive-behavioral therapy |
Adapting CBT for older patients
When using CBT with older patients, it is important to keep in mind characteristics that define the geriatric population. Laidlaw et al30 developed a model to help clinicians develop a more appropriate conceptualization of older patients that focuses on significant events and related cognitions associated with physical health, changes in role investments, and interactions with younger generations. It emphasizes the need to explore beliefs about aging viewed through each patient’s socio-cultural lens and examine cognitions in the context of the time period in which the individual has lived.
Losses and transitions. For many older patients, the latter years of life are characterized by losses and transitions.31 According to Thompson,31 these losses and transitions can trigger thoughts of missed opportunities or unresolved relationships and reflection on unachieved goals.31 CBT for older adults should focus on the meaning the patient gives to these losses and transitions. For example, depressed patients could view their retirement as a loss of self worth as they become less productive. CBT can help patients identify ways of thinking about the situation that will enable them to adapt to these losses and transitions.
Changes in cognition. Changes in cognitive functioning with aging are not universal and there’s considerable variability, but it’s important to make appropriate adaptations when needed. Patients may experience a decline in cognitive speed, working memory, selective attention, and fluid intelligence. This would require that information be presented slowly, with frequent repetitions and summaries. Also, it might be helpful to present information in alternate ways and to encourage patients to take notes during sessions. To accommodate for a decline in fluid intelligence, presenting new information in the context of previous experiences will help promote learning. Recordings of important information and conclusions from cognitive restructuring that patients can listen to between sessions could serve as helpful reminders that will help patients progress. Phone prompts or alarms can remind patients to carry out certain therapeutic measures, such as breathing exercises. Caretakers can attend sessions to become familiar with strategies performed during CBT and act as a co-therapist at home; however, their inclusion must be done with the consent of both parties and only if it’s viewed as necessary for the patient’s progress.
