Evidence-based psychological treatments for distress in family caregivers of older adults

This review identifies evidence-based psychological treatments (EBTs) for reducing distress, and improving well-being, of family members caring for an older relative with significant cognitive and/or physical impairment. Three categories of psychologically derived treatments met EBT criteria: psychoeducational programs (N = 14 studies), psychotherapy (N = 3 studies), and multicomponent interventions (N = 2 studies). Specifically, support within the psychoeducational category was found for skill-training programs focused on behavior management, depression management, and anger management and for the progressively lowered threshold model. Within the psychotherapy category, cognitive-behavioral therapy enjoys strong empirical support. Within the multicomponent category, programs using a combination of at least 2 distinct theoretical approaches (e.g., individual counseling and support group attendance) were also found to be effective. Suggestions for future research include the development of more well-integrated multicomponent approaches, greater inclusion of ethnically diverse family caregivers in research protocols, and greater incorporation of new technologies for treatment delivery.     

Commentary on evidence-based psychological treatments for older adults

This article comments on the articles in the Special Section on Evidence-Based Psychological Treatments for Older Adults. The articles apply criteria developed by the Society of Clinical Psychology to evaluate treatments for late-life anxiety, insomnia, behavior disturbances in dementia, and caregiver distress. The articles document that there are evidence-based psychological treatments that can help older adults. However, there are 2 substantial hurdles: evidence and access. Gaps in the evidence, as mentioned by the authors of the articles in the special section, result from disproportionate research attention to some psychotherapies and some mental disorders, with corresponding lack of research about other treatments and disorders. The challenge for access is to ensure that older adults with treatable mental disorders will get connected to psychologists trained in these evidence-based therapies.     

Procedures for identifying evidence-based psychological treatments for older adults

The authors describe the methods used to identify evidence-based psychological treatments for older adults in this contribution to the special section. Coding teams were assembled to review the literature on several problems relevant to mental health and aging. These teams used the manual developed by the Committee on Science and Practice of the Society for Clinical Psychology (Division 12) of the American Psychological Association that provided definitions of key constructs used in coding. The authors provide an overview of the process followed by the review teams and of some of the issues that emerged to illustrate the steps involved in the coding procedure. Identifying evidence-based treatments is a fundamental aspect of promoting evidence-based practice with older adults; such practice is advocated by most health care disciplines, including psychology.     

Evidence-based psychological treatments for late-life anxiety

This project identified evidence-based psychotherapy treatments for anxiety disorders in older adults. The authors conducted a review of the geriatric anxiety treatment outcome literature by using specific coding criteria and identified 17 studies that met criteria for evidence-based treatments (EBTs). These studies reflected samples of adults with generalized anxiety disorder (GAD) or samples with mixed anxiety disorders or symptoms. Evidence was found for efficacy for 4 types of EBTs. Relaxation training, cognitive-behavioral therapy (CBT), and, to a lesser extent, supportive therapy and cognitive therapy have support for treating subjective anxiety symptoms and disorders. CBT for late-life GAD has garnered the most consistent support, and relaxation training represents an efficacious, relatively low-cost intervention. The authors provide a review of the strengths and limitations of this research literature, including a discussion of common assessment instruments. Continued investigation of EBTs is needed in clinical geriatric anxiety samples, given the small number of available studies. Future research should examine other therapy models and investigate the effects of psychotherapy on other anxiety disorders, such as phobias and posttraumatic stress disorder in older adults.     

Evidence-based psychological treatments for disruptive behaviors in individuals with dementia

In this article, the authors review the literature regarding evidence-based psychological treatments (EBTs) for behavioral disturbances in older adults with dementia, as proposed by the American Psychological Association's Committee on Science and Practice of the Society for Clinical Psychology. Fifty-seven randomized clinical trials were reviewed for inclusion on the basis of titles or abstract information. Forty-three were excluded either because they did not meet EBT methodological criteria or because they involved environmental or psychoeducational nursing interventions in which the psychological component could not be separately evaluated. Fourteen studies were considered for inclusion as EBTs; of these, 8 showed significant differences between treatment and control groups. Results of this review indicate that behavioral problem-solving therapies that identify and modify antecedents and consequences of problem behaviors and increase pleasant events and individualized interventions based on progressively lowered stress threshold models that include problem solving and environmental modification meet EBT criteria. Additional randomized clinical trials are needed to evaluate the generalizability and efficacy of these and other promising psychological interventions in a variety of settings with individuals who have a range of cognitive, functional, and physical strengths and limitations.     

A cognitive-behavioral therapy for sleep-maintenance insomnia in older adults.

Older adults (3 men, 4 women, aged 55 to 68 years) with chronic sleep-maintenance insomnia were treated sequentially with relaxation therapy (RT) and then with a cognitive-behavioral therapy (CBT) specifically designed for alleviating sleep maintenance problems. Sleep diaries and an objective measure of sleep, the sleep assessment device, showed only modest improvements in measures of wake time after sleep onset, sleep efficiency, and night-to-night sleep variability following RT. However, significant improvements in these measures were observed following CBT and at a 3-month follow-up. These findings, considered in conjunction with previous reports, suggest that CBT specifically addresses factors that sustain sleep maintenance complaints. Additional trials of CBT with larger samples are warranted.     

A controlled comparative investigation of psychological treatments for chronic sleep-onset insomnia

A sample of physician-referred chronic insomniacs was randomly allocated to either progressive relaxation, stimulus control, paradoxical intention, placebo or no treatment conditions. Treatment process and outcome were investigated in terms of mean and standard deviation (night to night variability) measures of sleep pattern and sleep quality. Only active treatments were associated with significant improvement, but the nature of treatment gains varied. In particular, stimulus control improved sleep pattern, whereas relaxation affected perception of sleep quality. All improvements were maintained at 17 month follow-up. Results are discussed with reference to previous research and guidelines are given for clinical practice.     

Advancing cognitive behaviour therapy for older adults with comorbid insomnia and depression

Insomnia and depression are two of the most common mental health problems that negatively impact older adults. The burden associated with these highly comorbid conditions requires an innovative approach to treatment. There have been significant advancements in the field of cognitive behaviour therapy for insomnia (CBT-I) over recent years. CBT-I has evolved from targeting homogenous insomnia samples to now showing promising results for comorbid insomnia. CBT-I is not only effective at treating comorbid insomnia, but can also have a positive impact on depression severity. Despite these important clinical developments, limited research has explored whether modifying CBT-I programmes to specifically target comorbid depression could improve outcomes for older populations. This paper reviews recent literature and provides therapeutic recommendations to advance CBT-I for older adults with comorbid insomnia and depression.     

Urinary incontinence and psychological distress among older adults

We examined the relationship between urinary incontinence and psychological distress in a sample of community-dwelling older adults. The data are from a probability sample of Washtenaw County, Michigan residents ages 60 years and older, who were interviewed in 1983 and 1984. A total of 747 women and 541 men were included in the analyses. Experiencing urinary incontinence, particularly in a severe form, was weakly related to depression, negative affect, and low life satisfaction. These relationships are partly explained by the fact that incontinent respondents are less healthy than are continent respondents.     

Primary versus secondary insomnia in older adults: subjective sleep and daytime functioning

Most psychological research on insomnia has centered on primary insomnia (PI). Secondary insomnia (SI), though more common than PI, has received little attention because of its presumed unresponsiveness to treatment. The present study recruited older adults with PI, SI, and a comparison group of older adults with no insomnia (NI). Self-report assessments of sleep revealed no significant difference between the 2 insomnia groups. Daytime functioning measures found significant differences in impairment between the 3 groups with SI having the worst daytime functioning, followed by PI, which was worse than NI. Further analyses found substantial independence between sleep and daytime functioning. Implications of these findings for the clinical management of SI are discussed.     

Self-efficacy and compliance with benzodiazepine taper in older adults with chronic insomnia.

Better understanding of compliance with BZD taper is warranted. Compliance with a taper program and perceived self-efficacy (SE) in being able to comply with hypnotic reduction goals was monitored weekly in 52 older adults (mean age: 63.0 years) with chronic insomnia (average duration: 21.9 years) who underwent a 10-week physician-supervised medication tapering. One group received cognitive- behavior therapy for insomnia during discontinuation, whereas the other did not. Compliant patients showed higher SE ratings at Weeks 6, 8, 9, and 10. Medication-free patients at the end of the treatment also reported higher mean SE ratings at those 4 weeks. Differences remained significant when withdrawal symptoms and sleep efficiency were controlled for. These results have important clinical implications because SE may indicate key time points when patients are experiencing more difficulty during discontinuation.     

Coping success and its relationship to psychological distress for older adults.

The role of coping success on psychosocial distress was investigated in 147 older adults who experienced a major health problem and 82 older adults who reported a major loss in the past 6 months. Home interviews provided data on satisfaction with coping efforts and negative changes associated with events. Significant predictors of coping success were identified and controlled for in subsequent analyses predicting mental health. Efficacy in coping with loss was associated with less psychological distress. Coping efficacy interacted with coping efforts in predicting distress for those with health downturns; efficacy in coping was associated with less distress only for those who were actively engaged in coping. Analyses of longitudinal data replicated the cross-sectional findings for coping with loss.     

Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age.

Meta-analyses support the effectiveness of behavioral interventions for the treatment of insomnia, although few have systematically evaluated the relative efficacy of different treatment modalities or the relation of old age to sleep outcomes. In this meta-analysis of randomized controlled trials (k = 23), moderate to large effects of behavioral treatments on subjective sleep outcomes were found. Evaluation of the moderating effects of behavioral intervention type (i.e., cognitive-behavioral treatment, relaxation, behavioral only) revealed similar effects for the 3 treatment modalities. Both middle-aged adults and persons older than 55 years of age showed similar robust improvements in sleep quality, sleep latency, and wakening after sleep onset. A research agenda is recommended to examine the mechanisms of action of behavioral treatments on sleep with increased attention to the high prevalence of insomnia in older individuals.     

Behavioral treatment of insomnia in older adults: an open clinical trial comparing two interventions

Fifty-five insomniacs, 60 years or above, participated in a behavioral treatment program, comparing two interventions (sleep hygiene+stimulus control vs sleep hygiene+relaxation tape). Half of the subjects were randomized to a waiting-list condition prior to treatment. No significant changes were observed during the waiting-list period. During the treatment period however, the subjects improved on several sleep parameters, and treatment gains were maintained at a 6-month follow-up. The effects of treatment were greater for nocturnal measures (e.g. sleep onset latency and total sleep time) as compared to daytime measures (e.g. life satisfaction, daytime alertness) and not-targeted behavior (medication use). There were no differences in treatment effects for the two interventions.     

Sleep patterns and aging: comparison of older adults with and without insomnia complaints

The nature of geriatric insomnia was studied by comparing older adults with (n = 42) and without (n = 30) insomnia complaints on measures of sleep, mood, life-style, health, and sleep-requirement expectations. Elderly persons with insomnia complaints reported longer sleep latency and more frequent and longer awakenings and used sleeping aids more often than those without insomnia complaints. Nocturnal sleep time was not a reliable discriminator. Poor sleepers showed greater discrepancies between their current sleep patterns and sleep-requirement expectations than did good sleepers. Elderly insomniacs acknowledged greater symptomatology of depression and anxiety than did good sleepers. Daytime napping and physical exercise were equivalent in both groups. Medical disorders, pain conditions, and drug usage (other than sleep aids) did not distinguish the two groups. Clinical implications for the treatment of geriatric insomnia are discussed.     

Comparative risk and perceived control: implications for psychological and physical well-being among older adults

As older adults become more susceptible to certain health crises, their preoccupation with their risk of suffering such events increases. Understanding the implications of risk perceptions is critical because they may have consequences for psychological and physical well-being in later life. In the present study of older adults living in the community, the authors examined participants' comparative risk estimates (CREs)--their perceptions of their own risk relative to a similar other's risk--of suffering a hip fracture. Using multiple regression analyses, the authors examined the role of CREs on psychological well-being (negative emotions, life satisfaction) and self-rated physical well-being (general physical health, recent physical health). The authors expected perceived control (PC) to moderate the relationship between CREs and well-being. The predicted interaction did occur: Among individuals with high PC, comparative optimism (perceiving a comparatively low risk) was associated with better psychological well-being (fewer negative emotions and greater life satisfaction) and better physical well-being (general and recent physical health) relative to comparative pessimism (perceiving a comparatively high risk). Among individuals with low PC, there were no differences in well-being between comparative optimists and comparative pessimists. These findings suggest that the protective effect of comparative optimism on well-being is limited to older adults who have a strong sense of control.     

Evidence-based assessment of depression in adults

From diverse perspectives, there is little doubt that depressive symptoms cohere to form a valid and distinct syndrome. Research indicates that an evidence-based assessment of depression would include (a) measures with adequate psychometric properties; (b) adequate coverage of symptoms; (c) adequate coverage of depressed mood, anhedonia, and suicidality; (d) an approach to suicidality that distinguishes between resolved plans and preparations and desire and ideation; (e) assessment of the atypical, seasonal, and melancholic subtypes; (f) parameters of course and chronicity; and (g) comorbidity and bipolarity. These complexities need to be accounted for when certain assessment approaches are preferred, and when ambiguity exists regarding the categorical versus dimensional nature of depression, and whether and when clinician ratings outperform self-report. The authors conclude that no one extant procedure is ideal and suggest that the combination of certain interviews and self-report scales represents the state of the art for evidence-based assessment of depression.