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Elderly

Elderly. Psychological Assessment Treatment and Management. Mood Disorders. Depression severe in 4% over 65’s mild in 13% over 65’s Anxiety 3% generalised anxiety 10% phobic disorders. Depression in the Elderly. Symptoms 15% community residents > 65years Major depression

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Elderly

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  1. Elderly • Psychological Assessment • Treatment and Management

  2. Mood Disorders Depression • severe in 4% over 65’s • mild in 13% over 65’s Anxiety • 3% generalised anxiety • 10% phobic disorders

  3. Depression in the Elderly Symptoms • 15% community residents > 65years Major depression 3% in community 5% in primary care clinics 25% nursing home residents • High in chronic medical conditions which limit functional abilities

  4. Recovery from Depression • Livingston & Hinchcliffe 1993 • 33% remain depressed 3 years later • Only 20% make complete recovery • Burvill 1993 • 47% complete recovery over a year • 18% recover & relapse • 24% remain depressed • 11% died

  5. Drug treatments available but • problems in long term use • relapse rates high • many do not recover completely • 10% do not improve at all Scope for psychological treatments

  6. Therapies • Anxiety disorders • Depression • Grief therapy • Insomnia • Family involvement • Other

  7. Treatment of Affective Disorders • Physical health • Cognitive decline • Loss • Patient expectations • Therapist expectations • Rambling

  8. Anxiety Disorders • Sullivan et al 1988 • 13% on medication • 60% of these still were 3 years later • Morgan 1987 sleep disorders • 20% men • 30% women • over 70 reported trouble with sleeping

  9. Anxiety • Specific fears • Falling • Crime • Dying • Graded exposure • PTSD • Robbins (1994) 16% veterans WW2 • Speed et al (1989) 29% POW • Debriefing

  10. King and Barrowclough 1991 • Cognitive behavioural intervention in 10 community patients with anxiety disorders • Treatment • assisting person to reinterpret anxiety symptoms eg not life threatening but benign • hyperventilation provocation tests • 9/10 improved and this was maintained to 3 - 6 month follow up.

  11. Depression • CBT • Interaction behaviour, cognitions and emotions • Strategies to challenge and replace negative automatic thoughts • Relationship activity and mood • Reintroduction pleasant activities

  12. Case Example Mr B • 74 male retired architect • Caring for wife with emphysema • Sons married and lived away • Anxiety and depression as a result of caring for wife • Committed to caring for wife • Anxious when she is demanding and hostile • Ongoing difficulties since wife’s health began to decline

  13. Case Example Mr B • No previous depression • BDI score 20 • HRS 18 • Contract for 20 sessions CBT • Concerned about wife’s reaction to his involvement in therapy

  14. Case Example Mr B • Early phase • Difficult to attend therapy • Relaxation at beginning of session • Practice relaxation at home • Aim • To understand and challenge stressful beliefs • Increase pleasant, social activities • Reduce anxiety when needed to be assertive with wife

  15. Case Example Mr B • Middle Phase • Behavioural • Relaxation exercises • Identify pleasant events • Cognitive • Dysfuntional thoughts record • Assertiveness training • Final Phase • Maintenance guide • Booster session

  16. Pleasant Events Scale

  17. Dysfunctional Thought Record

  18. Assertive Rights

  19. Thompson et al 1987J Consult Clin Psychol 55: 385-90 cognitive therapy vs behaviour therapy vs brief psychotherapy vs waiting list • no sig. diffs in treatment groups • 52% moved out of depressed range • 18% substantial improvement • At 2 year follow-up 70% not depressed

  20. Thompson et al 1994 Combination of drugs and psychological therapies = often used • Desipramine vs • CBT (16 - 20 sessions) vs • Both CBT = Both > desipramine

  21. Bibliotherapy Scogin et al 1990 J Consult Clin Psychol 57: 403-407 • Mildly and moderately depressed elderly people • Bibliotherapy based on cognitive or behavioural approaches vs waiting list control • Both self-help books reduced depression, on Hamilton scale and self-report measure, compared to controls • 2/3 showed clinically significant change • Gains maintained at 2 year follow-up

  22. Group Therapies • Steuer et al 1984 • Psychodynamic = CBT group therapy • 40% drop out during therapy • Of those who completed 9 months therapy • 40% in remission • 40% symptom reduction • Ong et al 1987 • Weekly support group • 7/10 controls rereferred to hospital • 0/10 intervention group rereferred

  23. Overviews • Scogin & McElreath 1994 • 17 trials • 765 participants over 60 years • Effect size 0.78 • Comparison between therapies showed no advantage of any approach

  24. but • which patients benefit most and least? • lack of differences because all encourage increased self- efficacy? • how do psychological therapies compare with drug therapies? • sleep disorders a major problem • group work for relapse prevention

  25. Mood Problems after Stroke CBT and chronic illness

  26. Mood Problems Depressed • 30-40% • independent of time since stroke • Robinson et al 1983 • 103/164 consecutively admitted • 27% major depression • 20% minor depression • 9% unduly cheerful

  27. Mood Problems • Wade et al 1987 • 976 acute strokes from 96 GPs • Definitely or probably depressed • 33% at 3 weeks • 32% at 3 months • 31% at 6 months • Collen et al 1987 • 500 admissions111 first stroke • WDI & GHQ28 at one year • 42% depressed on either measure • Using same criteria as Wade • 38% definitely depressed • 26% probably depressed

  28. Psychological Management • Kneebone & Dunmore 2000 • Brit J Clin Psy 39; 53-65

  29. Pilot Study Lincoln et al 1997 • Stroke patients • SCED • 4 weeks baseline • 10 weeks CBT • 19 stroke patients 8 - 109 weeks after stroke 8.4 sessions CBT (range 3-15)

  30. Results • Significant improvement on BDI (p=0.02) • No significant improvement on WDI (p=0.06) • No significant improvement on HAD-D (p= 0.27)

  31. Single Case Analyses consistent benefits 4 some benefit 3 minimal benefit 3 no benefit 9 Total 19 patients

  32. Discussion • Results suggested RCT justified • Clinical Rehabilitation 1997; 11: 114-122 • RCT • Lincoln & Flannaghan 2003 Stroke

  33. Patients on a stroke register screened using BDI & WDI at 1m 3m & 6m S.C.A.N RANDOMISATION PLACEBO TREATMENT CONTROL Visited by Blind Independent Assessor at 3m & 6m post S.C.A.N

  34. Attention Placebo • general conversation • discussing problems • no strategies suggested • no advice to carers or hospital staff • 10 sessions in 3 months

  35. Cognitive Behaviour Therapy • based on manual produced for pilot study • delivered by trained experienced therapist • advice to carers and hospital staff • 10 sessions in 3 months

  36. Outcome on Beck Depression Inventory

  37. Outcome on GHQ28

  38. Discussion • Patients were not seeking help • High co-morbidity • Early intervention if recruited at one month

  39. Is CBT an appropriate strategy? • 50 stroke patients • Cognitions significantly related to mood • CQ with BDI rs 0.81 p<0.001 • CQ with WDI rs 0.80 p< 0.001

  40. Reduction in distress • Significant problem • Limited evidence for effectiveness • Multi-component packages • Depends on nature of routine care already provided • Measurement Problems

  41. Therapies • Anxiety disorders • Depression • Grief therapy • Insomnia • Family involvement • Other

  42. Grief Therapy • Most elderly experience many losses • Many bereaved, including elderly do not experience depression after the loss • Initial reaction stable over next few years • Depressed mourners may be depressed prior to death or have long standing difficulty coping with stressful events • Need to differentiate hopelessness and helplessness from realistic appraisal

  43. Insomnia • Prevalence increases with age • Treatment • Sleep health education • Stimulus control • Relaxation • Cognitive

  44. Family Involvement • Family therapy • Marital relationships • Siblings and spouses • Intergenerational problems • Methods • Information • Advice • Life review • Genogram

  45. Other problems • Sexual • Paranoid delusions • Problem drinking

  46. Background Reading • Lindsey, S.J.E. & Powell, G.E. 1994 The Handbook of Adult Clinical Psychology. Routledge Chapters 21 and 22 • Woods, R.T. Handbook of the Clinical Psychology of Ageing. Wiley 1996. • Woods, R.T. Psychological Therapies and their efficacy. Reviews in Clinical Gerontology, 1992, 2, 171-183. • Morris, R.G. & Morris L.W. Cognitive and behavioural approaches with the depressed elderly. Int. Journal of Geriatric Psychiatry, 1991, 6, 407-413.

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