Psychotherapy for Elderly With Dementia: What’s the Point?

It sounds cold and unfeeling to some. But, it’s a legitimate question. It pushes at many of our predispositions and prejudices in regard to the elderly. Moreover, there’s rationale in the question. After all, when someone loses cognitive abilities for language and reason, just exactly what can the couch offer? Actually, a lot of research supports it. Time and again it is shown that psychotherapy can improve the quality of life of those with dementia by reducing the symptoms of depression and anxiety.

It’s important to know the scope of the problem. 8-15% of those over 65 have Alzheimer’s. 4.6 % are severe. Over 85 the severe reach 15%. Of that population, it is estimated that 90% suffer psychiatric disturbances. 50-75% suffer depression.

First, a little exploration into psychotherapy itself without getting too complicated. There are many varieties of psychotherapy. We’ve been culturally conditioned to think of psychotherapy strictly as the kind that Freud developed that involves a deep, long and analytical exploration of one’s past, particularly childhood. We think of Woody Allen and years of work. This is NOT the form that is usually advised for this population. Obviously, this is not practical where there are such memory and cognitive deficits.

However, there are other forms of treatment. Some of these are called cognitive-behavioral, behavioral and supportive psychotherapy. All of these have been found to varying degree to be efficacious for those with dementia. In many instances, the therapies are able to avoid, delay or reduce the amounts of psychopharmacological substances that might be used. There’s certainly a place for psychiatric medicines for those with dementia. The acetylcholinesterase inhibitors (ie., Aricept) offer the possibility of salvaging cognition to a certain degree in a way that psychotherapy does not. However, in the realm of emotions and behavior (i.e., depression and anxiety), the available meds sometimes carry risks and side effects that are not desirable (i.e., risk of falls, sleepiness, etc…). It is thought that general good practice calls for initially trying non-biologic interventions. And, often the combination of psychotherapy and medicine is powerful and efficacious on an ongoing basis. In other words, very similar strategies as with those who are not demented.

But just how can it be? How is it that talking to someone who has lost memory for so much and whose language might be impaired can benefit from this process. Simply put, they may not remember details but they do know how they feel. It is estimated that 50-75% of those with Alzheimer’s are clinically depressed. Feelings live on. Sadness, agitation, shame, powerlessness, hopelessness are all quite alive in the minds and hearts of those with dementia. And it is the skill of the clinician to detect and address these.

 

Detection.

This can be a challenge with those who are demented. The poverty of language is an obstacle. Moreover, there really is a predilection with this generation to not acknowledge vulnerability. Again, the memory for details may be limited but personal values often transcend. Personality and character can change. But, not always and not usually absolutely. Therefore, the caregivers need to observe and note tearfulness, withdrawal, inactivity, agitation, anhedonia, etc…

Finally, what are some of the methods that the psychotherapist uses? Here are a few:

Behavioral– increase pleasant interactions, teach methods to control their environment, distraction, supervised exercise

Cognitive-behavioral– discussing feelings about memories they do have, problem solving.

Supportive– recalling calming memories, listening to tapes of friends and family members, inspiring, reassuring, suggesting, persuading, bolstering self-esteem.

And then there’s the one very surprising way that therapy reduces depression for those with dementia. It’s counseling for their caregivers. Research shows a significant decrease in depression for those with dementia when their caregivers engage in problem solving counseling. Caregivers can be family, friends, staff, etc… Remarkable. Help the helpers and you can help the helped