Driven to despair by her husband's death, a 70-something woman was suicidal by the time she landed in the office of psychologist Dolores Gallagher-Thompson, PhD. Gallagher-Thompson, director of the Older Adult and Family Center at the Palo Alto Veterans Administration (VA) Medical Center and an associate professor of psychiatry at Stanford University School of Medicine, went to work. First she tackled the patient's cognitive distortions, helping her see that it wasn't true that death had taken everyone who meant something to her. Then she helped the patient alter her behavior, urging her to reach out to others.
By the time the treatment was over, the woman was exploring newfound relationships with her grandchildren, working part-time for an accountant and enjoying a new sense of meaning in her life.
As the number of older Americans soars, Gallagher-Thompson and other psychologists are applying a wide variety of behavioral techniques to help them face the challenges that often accompany aging. Often working interdisciplinarily with physicians and other professionals, psychologists are using everything from cognitive-behavioral therapy for managing depression to biofeedback for treating incontinence. They're providing psychoeducation to help older patients comply with treatment regimens and handle pain. They're even using cognitive training to enhance older people's driving skills.
Doing so, they're convinced, not only improves patients' quality of life but lowers costs by reducing inappropriate use of medication and medical services.
Treating psychological concerns
Take Gallagher-Thompson, for instance. A decade ago, she and her psychologist husband Larry W. Thompson, PhD, pioneered a behavioral intervention they have since used to treat depression in more than 1,000 older people. Now widespread both in and out of the VA, the intervention focuses on teaching patients practical coping skills such as cognitive reframing, assertiveness and relaxation. A manual for therapists and workbook for patients guide the interventions.
Over the course of 10 to 20 sessions, patients tackle the workbook modules their therapists decide they need. Many patients focus on identifying and challenging unproductive thinking patterns. A therapist might help a recently retired man learn why it's not adaptive to think his life no longer has worth, then help him explore spirituality or other sources of meaning. Other older people might simply need to increase the amount of pleasure in their lives by star-gazing or calling friends. Still other patients might focus on assertiveness or relaxation skills.
"A lot of older people are very passive in their interactions with other people, especially when they're depressed," says Gallagher-Thompson, noting that while fewer than 5 percent of older people have full-blown depression, the rate jumps to 50 percent for those who are physically ill and 70 percent for those living in nursing homes. "It's also very common for anxiety and depression to co-exist in older people."
No matter which modules they use, all patients do homework and keep journals. This work culminates in the intervention's final step, the creation of a "survival notebook." In this module, patients and their psychologists work together to identify warning signs of depression, predict situations that might prompt it over the next year and develop a plan for preventing a slide back.
Gallagher-Thompson also has empirical proof that her approach works. In a recent study, she and her husband looked at the effects of antidepressants alone, their cognitive-behavioral approach and a combination of the two. They found that their approach worked as well as both the medication and the combination for people with moderate depression. Among patients with severe depression, the combination worked best.
"A lot of our patients at the VA are medically ill and can't take antidepressants because they interfere with the other medications they're on or have side effects that are so difficult to manage they don't comply with their treatment," Gallagher-Thompson explained. "That's how we got into cognitive-behavioral therapy in the first place."
Coping with physical problems
Other behavioral interventions target ostensibly physical problems. Kathryn L. Burgio, PhD, has developed a way of helping older women with sudden, overwhelming urges to urinate regain continence. Burgio, a professor of gerontology and geriatric medicine at the University of Alabama at Birmingham, uses biofeedback to help women learn to hold their bladders by contracting and relaxing their pelvic muscles. In a study published in the Journal of the American Medical Association, (1998, Vol. 280, p. 1995-2000) Burgio worked with 197 women age 55 to 92 to compare the effectiveness of biofeedback training, drug treatment and a placebo. She randomly assigned the women to receive four sessions of biofeedback training, daily doses of oxybutynin chloride or a placebo.
The results were striking. The women in the behavioral group reduced their incontinence by 81 percent, compared with 69 percent for the medication group and 39 percent for the placebo group. What's more, 97 percent of the women in the behavioral group felt comfortable enough with the exercises to continue them indefinitely.
This safe, effective treatment should be made more readily available to patients as a first line of treatment, says Burgio, noting that urinary incontinence is the second most common reason people end up in nursing homes.
Behavioral interventions are also helping older patients adhere to treatment regimens, says Jennifer Moye, PhD, director of the Geriatric Mental Health Clinic at the Brockton VA Medical Center in Brockton, Mass., and an assistant professor of psychiatry at Harvard Medical School.
Working as part of a VA demonstration project called Unified Psychogeriatric Biopsychosocial Evaluation and Treatment, Moye screens medical patients for anxiety, depression, alcohol abuse and other problems that may be interfering with medical treatment. When she identifies problems, Moye works with patients to explore underlying mental health issues and educates them about how those issues affect their prognoses. She reviews appointment and medication schedules with patients. She might even help patients fill their pill boxes.
Offering medical patients flexible, individualized treatment can improve their mental and physical health, says Moye, citing as an example an older architect whose fears of becoming dependent upon others prevented him from keeping his ulcerated legs elevated. Moye sat down with the patient to discuss his fears and explain the importance of compliance. She enrolled him in a support group of older men with health problems. And she met with his wife and discovered that early-stage Alzheimer's disease was preventing her from giving her husband the help his doctors expected of her.
Today the man is doing well, says Moye. Stories like his are saving the VA system money, she adds, noting that the project is showing a cost-savings of about $2,000 per patient per year.
Other psychologists are using behavioral interventions to help patients cut back on pain medication. Gail E. Wright, PhD, clinical manager of mental health services at the Harry S. Truman Memorial Veterans Hospital in Columbia, Mo., helps patients with rheumatoid arthritis find alternatives to medication.
"The first thing we do when patients are sent to us by a physician is ask them what they do to make themselves feel better," says Wright. "It's always a warning sign that they need an intervention if all they say is, 'I go to the doctor and take the medication he gives me.'"
The most important part of these individualized interventions is helping people regain a sense of control in the face of a degenerative condition and uncertain prognosis, says Wright. A patient might have arm pain so severe she can no longer hold her grandchildren, for instance. Over half a dozen sessions, Wright might help the patient explore alternatives, such as sitting side-by-side with the grandchildren to read a story. She might suggest alternative ways of coping with pain, such as heat, rest and exercise. And she might teach the patient relaxation techniques.
"When patients return again and again to their physicians complaining of pain, the physicians can wind up increasing their medication," says Wright, noting that there's more of a statistical correlation between pain and depression than between pain and physiological symptoms in these patients. "With our intervention and some therapy for depression, they regain a sense of self-efficacy."
Tackling everyday challenges
Not all the behavioral interventions that psychologists use target physical or mental health problems, however. Some are designed to increase older people's day-to-day autonomy. Karlene Ball, PhD, for instance, has developed an intervention to help older people drive more safely.
"Loss of mobility has lots of negative consequences," says Ball, a psychology professor at the University of Alabama at Birmingham. "If someone has to stop driving and there aren't readily available sources of alternative transportation, that's one of the pretty potent indicators of having to move from his or her home into some kind of assisted living situation."
Through her work on age-related vision changes, Ball found that older people often complained that vision problems were making driving difficult. But when older people were put through a roster of cognitive and visual tests, she found that the problem was not vision but slowed-down cognitive processing: They simply couldn't process fast enough to keep up with other cars suddenly veering into view or signs whizzing by. In fact, Ball found that processing ability was the best measure of predicting which older drivers would crash.
Fortunately, changes in processing speed aren't immutable. In a project funded by the National Institute on Aging and the National Institute on Nursing Research, Ball is using 10 computerized training sessions to help older people improve their processing speed. As driving scenes flash onto the screen, participants respond to questions such as the location or type of vehicles. As they improve, the tasks grow more difficult. According to Ball, participants are not only improving their speed but also transferring those skills to real-world driving.
Says Bell, "The longer we can keep people driving, the better it is for them personally and for the health-care system as well."
Rebecca A. Clay is a writer in Washington, D.C.
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