Adapting Ct For The Older Patient

After compiling a thorough examination of Mr. Z's physical, cognitive, and environmental risk factors, his therapist determined that in addition to working with Mr. Z's physician to help get his diabetes under control and linking Mr. Z to some much need social services, he would be an appropriate candidate for CT. Although his MMSE score was low, it was within normal limits; thus, the therapist determined that some modifications to the treatment would be helpful. Based on the results of the MMSE and observations during the intake, Mr. Z's therapist decided to begin the therapy by first introducing Mr. Z to all the concepts he would learn in CT: affect regulation strategies, activity scheduling, and communication skills. To facilitate learning, the therapist illustrated these new concepts using examples from Mr. Z's past, so that the new concepts were linked to well-learned events. Furthermore, Mr. Z was provided both written and audiotaped educational materials as aides in learning the new skills. During sessions, the therapist engaged in "cue and review" techniques that allowed Mr. Z several opportunities to encode the new information. The therapist also took into consideration Mr. Z's physical limitations and offered to provide CT in his home. Finally, the therapist was available to Mr. Z between sessions to reinforce the use the new strategies between sessions.

CT for late-life depression is very similar to CT for other populations, with only a few modifications. There is typically a psychoeducational component to educate the patient about cognitive theory of depression and the process of therapy; a focus on challenging pessimistic thinking; behavioral activation strategies; and other skills-based training as needed (social skills, anxiety management, time management, and problem solving). Therefore, the modifications to CT focus largely on accounting for age-related changes in cognitive functions that impact new learning and attention; accounting for physical disabilities; adjusting the therapeutic frame to allow for disability and the numerous demands that older people have on their time and energy; and a consideration of cohort beliefs. Thus, CT content does not change; rather, the means by which it is presented and the speed at which information is acquired are different for older patients. Table 18.1 summarizes this

TABLE 18.1. Late-Life Adaptations for CBT

Age-related challenge

CBT process

Adaptation

Disability; time constraints; instrumental barriers

Therapeutic frame; frequency of visits

Home/telephone-based therapy; case management

Learning novel concepts

Overall knowledge acquisition

Tie new information to overlearned and contextual information

Verbal recall

Thought records; differentiating thought from feeling

Simplify terms and forms; avoid jargon

Perceptual speed

Homework; adherence; session time

Increase number of sessions; simple homework; schedule time for homework; telephone support

Attention and focus

Structured tasks; information gathering; weighing the evidence

Redirection

Working memory

Learning new skills

Cue and review; multimodal presentation

Isolation

Termination

Early fading; relapse prevention; booster sessions

section by listing the CT strategy, the age-related challenge in using the strategy, and the modification that address these challenges.

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