Normal age-related changes in cognition do not usually interfere with psychotherapy.12 However, minor impairments may complicate treatment. There are few studies of psychotherapy for late-life depression in older adults with cognitive complaints, with the exception of older adults with mild to moderate executive dysfunction—a common cognitive complaint in most people with depression and a noted risk factor for poor response to antidepressants.1,12
Only PST has been rigorously studied and found to be effective in depressed older adults with mild executive dysfunction.13,14 There have been no large-scale studies of IPT for depression in older adults with mild memory complaints.15 CBT has been researched as an intervention for depression in older adults with moderate dementia, but the results have not been positive.16 A recent systematic review found that the most effective interventions for persons who have dementia and neuropsychiatric symptoms are behavioral interventions that include assessment of the causes of the symptoms and plans to reduce or prevent symptoms from occurring.17
The success of learning-based therapies—CBT and PST—is most affected by a patient's memory impairment and cognitive slowing. To address problems associated with cognitive slowing when providing PST or CBT, present therapeutic material at a slower pace and over a longer period. Frequent demonstrations of the therapeutic technique with a generic example and regular in-session practice also help older patients learn new coping skills. By going slowly, you can gauge how well the patient understands the new skill.
Life review, a technique commonly used in reminiscence therapies, is an excellent tool for linking new material to past experiences.18
Finally, memory aids—such as notebooks to record information or the engagement of family members to help remind patients about between-session activities—may be useful.
Patients with disabilities
There has been considerable recent interest in psychotherapy for older adults who are homebound and disabled. PST can reduce depression and improve physical functioning in homebound and visually impaired older adults.19,20 IPT has not been rigorously studied as a depression intervention for disabled patients.
When working with disabled patients, it is important to provide information about available medical and social services. The therapeutic process may benefit from close, ongoing collaboration with other health care professionals, particularly in working with frail elderly patients with multiple medical problems. Some practical tips include:
• Offer visually impaired patients audiotaped sessions for at-home review
• Provide written information or forms in large print and with larger writing spaces to accommodate changes in fine motor skill
• Sit closer to the patient and speak slowly and in low tones to help those with hearing loss (microphones connected to headphones that amplify the clinicians voice can also be worn by patients)
Using older adults' strengths and resources
Older patients have a vast wealth of knowledge and experience that can be used to move them forward in their recovery. Although cognitive functions may be less efficient than those of younger adults, older adults' stores of experience can be used in learning new coping techniques and in developing effective strategies. Even past failures can be used to guide a different course of action for the future. The older adult's store of life experience coupled with psychotherapy for late-life depression can lead to highly effective treatment outcomes and a positive therapeutic experience for both the patient and the clinician. (The Table can be used as a guide for selecting the best psychotherapy for older patients.)
Although research on psychotherapy for older depressed patients has grown substantially, there are still unanswered questions. First, there have been no studies on the effects of psychotherapy for treating late-life depression with psychosis. Thus, it is not possible to recommend specific psychotherapies for this presentation of late-life depression.
Second, results from studies that have compared antidepressant medications with psychotherapy and from studies of combined treatments for late-life depression have been mixed. Antidepressants appear to be better than IPT for chronic, recurrent, late-life depression, but CBT appears to be as effective as antidepressants.21,22 Moreover, there has not been enough research to determine when antidepressants should be used in combination with or instead of psychotherapy. Patient preference is an important consideration when selecting treatments.
Third, although there is evidence that psychotherapy reduces depression symptoms overall, there has been no analysis of whether psychotherapy reduces specific symptoms.
Finally, there have been no studies of family-based therapies in late-life depression.