The use of cognitive behaviour therapy in the management of BPSD in dementia (Innovative practice)

Introduction

The prevalence of behavioural and psychological symptoms of dementia (BPSD) such as screaming and aggression is high, ranging from 35% to 85% and occurring in 78% of residents in nursing homes (Van Der Linde, Stephan, Savva, Dening, & Brayne, 2012). The rate of co-morbid depression in dementia is also considerable: 19% in a Dutch study (Verkaik, Francke, van Meijel, Ribbe, & Bensing, 2009) with low rates of remission (Wilkins, Kiosses, & Ravdin, 2010) and higher rates (up to 29%) in nursing homes (Stewart et al, 2014). The reliability of reported anxiety prevalence rates in dementia is affected by the lack of consensus regarding the symptoms of anxiety and agitation. The definition of ‘agitation’ is often vague, despite it being a common presentation of BPSD (Nordhus & Hynninen, 2010) and frequently a target for treatment. Therefore, the impact of depression and anxiety on the presentation and incidence of behavioural and psychological symptoms in dementia is significant. Furthermore, a degree of co-morbidity between the two conditions can result in further disability, with anxiety adversely affecting the outcome of treating depression (Cheok, Snowdon, Miller, & Vaughan, 1996).

However, detection and subsequent treatment are often lacking. The following paper aims to summarize the use of cognitive behaviour therapy in treating anxiety and depression in dementia, featuring its clinical utility in dementia care environments.

Support for psychological therapy in dementia

Cognitive behaviour therapy has been increasingly applied to treat depression and anxiety in older adults with several meta-analytic studies supporting its use (for example, Pinquart, Duberstein, & Lyness, 2006). Behavioural methods, such as those incorporating activity and pleasant events, have been particularly cited for their effectiveness (Verkaik, Van Weert, & Francke, 2005). Support for structured programs of activity is a common finding in systematic reviews of psychosocial methods in managing BPSD (e.g. Opie, Rosewarne, & O’Connor, 1999), and the use of relaxation training has been supported in older adults (Ayers, Sorrell, Thorp, & Wetherell, 2007). Several case report studies report the successful use of cognitive behaviour therapy for treating anxiety in dementia where modifications are described such as utilizing recordings or written summaries of sessions, emphasizing structure and using other people (collaterals) to enhance practice of techniques (Koder, 1998; Kraus et al., 2008). A program of cognitive behaviour therapy – ‘Peaceful Mind’ – describes in detail five modules aimed at decreasing anxiety: self-awareness (of triggers of anxiety and symptoms), breathing techniques, calming thoughts, simplified behavioural activation and sleep skills (Paukert et al., 2010). Again, the use of collateral caregivers was important in maximizing therapeutic effects, with decreased anxiety symptoms and high treatment satisfaction from pre- to post-treatment. A randomized controlled trial was recommended (Paukert et al., 2010).

In depression co-existing with dementia, programs (for example, BE-ACTIV; GIST program) have promoted behavioural activity scheduling (Hyer, Yeager, Hilton, & Sacks, 2009; Meeks, Looney, Van Haitsma, & Teri, 2008; Teri, Logsdon, Uomoto, & McCurry, 1997) in improving mood. The BE-ACTIV program or Behavioural Activities Intervention program contains interventions focusing on pleasant events and problem solving, with regular communication between the external therapist working with the individual and care staff (Meeks et al., 2008). The GIST program (group, individual and staff therapy) utilizes the format of repetition of one session containing key coping skills with staff or peers being used as ‘coaches’ in some sessions (Hyer et al., 2009). Here, such programs include care staff as an important adjunct to therapy. Moreover, psychosocial methods that are activity based have been linked to reducing BPSD in long-term care settings (Snowden, Sato, & Roy-Byrne, 2003).

A meta-analysis of psychotherapeutic approaches, including cognitive behaviour therapy and behavioural activation, gave rise to 17 randomized controlled trial studies with a medium effect size in terms of significantly reducing depression symptoms in residents of long-term care (Cody & Drysdale, 2013). Of note was the positive impact of including care staff in therapy delivery in enhancing effect sizes. This finding underscores the need for collaboration with others as an essential feature of cognitive behaviour therapy with depression and anxiety in dementia. A Cochrane Collaboration review (Orgeta, Qazi, Spector, & Orrell, 2014) examining the impact of cognitive behavioural treatment specifically for those with dementia, highlighted positive results in terms of decreasing depression in their report of six randomized controlled trials (N = 439).

Clinical relevance of cognitive behaviour therapy in dementia settings

One of the central tenets of cognitive therapy, namely collaborative exploration and gathering information, is congruent with a person-centred care philosophy integral to good management in dementia where knowledge of the person’s needs is paramount (Cohen-Mansfield & Mintzer, 2005). Adjusting to loss and the changes inherent in being placed away from one’s home (possibly following a period of illness) demands adaptation. Cognitive behaviour therapy promotes the development and utilization of skills, for example, coping with any anxiety associated with having to eat in a communal dining room or being in a new routine. Coping self-talk, rehearsal and structured relaxation techniques are therapeutic strategies that could be utilized in long-term care settings to cope with such adjustments. Furthermore, active coping strategies, more than health status, have been found to predict positive psychosocial functioning in long-term care (Schanowitz & Nicassio, 2006). On an individual level, assessment needs to identify a person’s strengths: ‘successful modification of CBT for persons with dementia depends on exploitation of preserved abilities and use of compensatory strategies for impaired abilities’ (Snow, Powers, & Liles, 2006, p. 272). The selective optimization with compensation model (Baltes, 1987) focuses on maximizing abilities of older people with cognitive impairment, as opposed to their deteriorations. This positive approach counteracts the helplessness often expressed by older people, particularly in long-term care.

Cognitive behaviour therapy can be successfully used to decrease behavioural and psychological symptoms of dementia and avoid inappropriate sedation and further disability. For example, a resident referred for refusing to leave her room (earning the potential label of ‘noncompliant’) may well suffer from an anxiety disorder. The author has seen frail older residents who present with the same symptoms of hyperventilation/panic attacks as in younger patients. Therefore, the focus needs to shift from ‘behaviour to be managed’, more to identifying potential behavioural clusters that can respond to evidence-based interventions. Identifying fear behaviours in a resident opens the door to anxiety management strategies that can be modified to successfully treat anxiety with the collaboration of family and staff (in this example, asking staff to exaggerate slow breathing that the resident can copy; having verbal and written prompts to slow down breathing; gradually increasing exposure to the environment outside of their room). This in turn engages staff as active collaborators in therapy. In the case of depression, calling out ‘help help’ or ‘I want to die’ may be a sign of a depressive disorder requiring treatment, as opposed to ‘inappropriate vocalization’. The content is highly relevant here. Such overt behaviours need to be carefully deconstructed in order to identify potential psychological disorders that can benefit from treatment.

Suggestions regarding how to promote the use of cognitive behaviour therapy in dementia

However, despite evidence in support of cognitive behaviour therapy, pharmacotherapy remains the most utilized treatment modality in long-term care facilities (Hyer et al., 2009). Access to psychological therapy for older adults in general is low compared to other age groups (Karel, Gatz, & Smyer, 2012; Laidlaw, 2013). Lack of interest and fewer geropsychology training opportunities can adversely impact on service delivery with few psychologists specializing in working with older adults (Koder & Helmes, 2008a). Assumptions on behalf of practitioners regarding the client’s ability to benefit from a ‘talking’ therapy, may impede treatment of depression or anxiety, especially in the context of cognitive impairment. Psychological therapies can be viewed by practitioners as being heavily reliant on intact cognitive abilities such as concentration, memory and concept formation thus rendering a client with dementia unsuitable for therapy.

The term ‘behavioural and psychological symptoms of dementia’ itself is widely used, especially in research settings and has come under criticism. This umbrella term is limiting and does not acknowledge individual factors that may be influencing how feelings and unmet needs are communicated. ‘In other words, we cannot treat people living with dementia as simply a collection of ‘symptoms’ or ‘challenging behaviours’ to be managed. People with dementia are individuals deserving care and respect, to be treated kindly and with dignity’ (Swaffer, 2015: 1). Shifting the concept from behaviours, to communication of individual wants and needs, as suggested by Swaffer (2015), would not only be less demeaning, but also more conducive to working collaboratively with people with dementia.

Encouragement for trainee psychotherapists to work in the field of geriatrics and gerontology is another important first step in increasing awareness about the benefits of psychological approaches. Having positive clinical exposure to dementia care settings whilst in training via clinical placements or rotations may counteract any previously held ageist beliefs regarding a cognitively impaired person's ability to benefit from a psychological therapy. Establishing relationships between universities and residential aged care facilities where students can be supervised on placement there (for example, Bhar & Silver, 2014), is helpful as clinical exposure during training has been found to positively influence a psychologist’s interest in working with older adult populations (Koder & Helmes, 2008b). Increasing the amount of gerontology and dementia-related content in training is also recommended. Exposing psychiatry and geriatrics trainees, such as registrars, to other multidisciplinary team members who practise psychological interventions may also increase awareness of alternatives and adjuncts to pharmacotherapy for psychological conditions. Involvement of a psychologist or other mental health professional can support and motivate care staff, as well as promoting awareness of mental health issues in residents (Powers, 2008).

Support for more treatment trials, or even encouraging clinicians to publish case series involving cognitive behaviour therapy in dementia care settings, would not only increase awareness of its potential but encourage new innovations. For example, there has recently been increased attention in the field of cognitive rehabilitation in the scientific literature (e.g. Naismith, Mowszowski, Diamond, & Lewis, 2013) with demonstrated benefits for participants’ mood. This has contributed to an increase in media attention and proliferation of group programs for those seeking to improve cognitive functioning. The increased use of technology in aged care settings such as iPads is also exciting (Leng, Yeo, George, & Barr, 2014).

Demonstration of cognitive behavioural techniques with not only direct care staff, but also their managers, is important in gaining support for its use in residential aged care facilities. Running regular education sessions with nursing and allied health staff and family members would improve awareness of cognitive behavioural therapy as an effective therapeutic intervention to improve residents’ mood and well-being. It may also provide simple, brief strategies that carers can use themselves, thus empowering them and making them collaborative participants in therapy, as recommended in the literature. Similar links are also recommended with general practitioners, as this professional group is in a good position to identify depression and anxiety and recommend treatments.

Conclusion

Dementia, per se, need not preclude people from accessing efficacious treatments. There needs to be more awareness and practice of psychological techniques for people with depression or anxiety who have co-morbid cognitive impairments. Practitioners working in the field of dementia need to also consider that overt behaviours or symptoms can be an expression of psychological distress.