Question 1

I've found therapy with older adults hard because they frequently present with overwhelming 'real life' challenges that are difficult to fix at their age eg. debt/low-income, health. Advice?

Ken Laidlaw · Accepted Answer

This is a common experience. Sometimes when working with older people they experience challenging age-related events such as stroke or diagnosis with a dementia, or life events such a loss of a spouse, onset of long term conditions, injuries etc. The key thing is to remember that CBT adopts a symptom-reducing problem-oriented focus. We should all remember the saying from the Stoic Epictecus, that people are not disturbed by things, but by the views they take of them. Thus, when working with what appear to be overwhelming and 'real life' problems start by trying to understand the meaning an individual attaches to these events and you may find a way to better understand their idiosyncratic perception and in so doing be better placed to help your client find a way to manage the problem. It is easy to feel demoralised and even deskilled at times when dealing with such problems, but knowing that the way we think about things when we are depressed or anxious is not usually helpful to us in managing our problems is also key to maintaining an expectation for change. As such seek to reduce the symptoms of depression and anxiety and start small, look for ways to help your client feel empowered. Age, alone rarely is the reason why people don't make progress but it is sometimes inadvertently used as a justification. Look at the life history of you client, and as you review, you may find that your client possesses a number of lifeskill developed from having overcome a number of adverse circumstances or setbacks over the years. This concept of 'lifeskill' suggest older people are resilient and will have learned a few things about dealing with difficulty. Perhaps you can talk to your clients about what they learned from overcoming difficulties in the past, and especially those situations when hope was in short supply. Perhaps some lessons from dealing with difficulties in the past can be used to overcome current problems? Good luck with your work.

Question 2

Can CBT help with anxiety about falling?

Ken Laidlaw · Accepted Answer

This is a very interesting and complex question as reasons for falls can be multifactorial. The consequences of falling can be quite severe, long-term and significant for older people so the fear of falling may result in significant difficulties resulting in activity avoidance and isolation. The issue is so important that the WHO produced a global report on falls prevention a few years ago. Results are conflicting on the question of whether CBT can help with fear of falling. NICE (National Institute for Health and Care Excellent) produced a clinical guideline in 2013 and noted that there is no evidence that CBT alone can reduce falls in community dwelling older people. Nevertheless, a recent meta-analysis published in 2018 by Liu et al.  suggests CBT may be effective in reducing fear of falling, rather than reducing falls, with suggestions that CBT may also produce a small effect size for improving balance. A multicomponent CBT intervention by Zijstra et al. in 2009 demonstrated positive outcomes in terms of fear about falling and in reducing activity avoidance behaviours. Results also look promising in a study reported by Parry et al. in 2018, who noted that CBT delivered by Health Care Assistants under supervision reduced fear of falling and reductions in depression in comparison to usual care. Overall, CBT seems to offer older people with fear of falling some hope of overcoming their anxiety and associated cognitive and behavioural consequences.

Question 3

Any advice for being a CBT therapist in a primary care setting with older adults?

Ken Laidlaw · Accepted Answer

Hi, well working in a primary care setting will expose you to a wide range of comorbid presentations of depression and anxiety. You will also come in contact with a range of colleagues who may have limited knowledge about CBT. One of the things you may wish to consider is increasing the knowledge of your primary care healthcare colleagues that CBT is efficacious with older people.  It is also probably going to be important to help people understand depression, and dementia for that matter, are not outcomes of age. You also need to be mindful that often mental health problems can be viewed as secondary to physical health problems and thus many people with depression and anxiety may not even be referred to you. Compounding this further is that older people themselves may not automatically ask for a referral to a CBT therapist. Another factor you can consider is  older people with  anxiety disorders and depression may be more likely to present to primary care with somatic symptoms and talk these up rather than affective or cognitive symptoms.  I'd advise you offer training sessions on CBT with older people and also bring it to people's attention that research shows older people prefer psychological therapy and rate it as more acceptable than medication for mental health problems.

Question 4

Does CBT need to be altered to be effective for older people?

Ken Laidlaw · Accepted Answer

This is a really interesting question. According to multiple empirical evidence sources from randomised controlled trials, to systematic reviews and even meta-analysis, the evidence seems clear, CBT is efficacious with older people. Naturalistic data from national service provision such as the improving access to psychological therapies (IAPT) suggest older people who receive standard non-modified CBT treatment protocols for depression and anxiety disorders also benefit from treatment. So, on the face of this evidence, the answer would appear to be no, CBT does not need to be altered for    it to be effective for older people. However, the answer is somewhat more nuanced. In CBT, individualizing treatment for any of the clients you work with is going to arguably improve outcome so in some respects we all need to alter CBT to 'fit' with our client rather than the other way around. Sometimes when working with older people their profile of symptoms and co-morbid conditions can make the case seem especially complex. In this event any alterations need to be evidence-based and likely to enhance outcome. They should also be consistent with the CBT model. Sometimes developments of CBT with older people, such as those living in residential care, or when working with the oldest-old do suggest that CBT does need to be altered in order to augment outcome but again these alterations are done thoughtfully and consistent with scientific practice.

Question 5

How can CBT help someone of older age who believes it is too late to change?

Ken Laidlaw · Accepted Answer

Evidence from naturalistic outcome from initiatives such as the Improving Access to Psychological Therapies (IAPT) in England and from research suggests older people achieve as good an outcome for CBT as those achieved by working age adults. When older people do engage in CBT  such as when offered through IAPT they tend to complete treatment and are less likely to drop out of treatment. More modern thinking suggests that as older people are developmentally more at ease with reflection  and review and more comfortable with tolerating different viewpoints, they may make ideal candidates for CBT. 
If someone, of any age, believes it is too late to change, we should see that as a symptom of their depression rather than a prediction, or even a determinant. We should remind our clients that CBT adopts a pragmatic, try it and see problem-solving orientation to managing their problems. Thoughts such as "I am too set in my ways' or "You can't teach an old dog new tricks" may seem compelling and convincing, however in CBT we know thoughts are not facts. Thankfully it is never too late to change and all we need do is to see starting CBT as a behavioural experiment, if it helps, great, if not then at least you have tried it.

CBT for Older People