Nancy Wilson

Cognitive Behavior Therapy for Generalized Anxiety Disorder Among Older Adults in Primary Care: A Randomized Clinical Trial

CONTEXT Cognitive behavior therapy (CBT) can be effective for late-life generalized anxiety disorder (GAD), but only pilot studies have been conducted in primary care, where older adults most often seek treatment. OBJECTIVE To examine effects of CBT relative to enhanced usual care (EUC) in older adults with GAD in primary care. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial recruiting 134 older adults (mean age, 66.9 years) from March 2004 to August 2006 in 2 primary care settings. Treatment was provided for 3 months; assessments were conducted at baseline, posttreatment (3 months), and over 12 months of follow-up, with assessments at 6, 9, 12, and 15 months. INTERVENTION Cognitive behavior therapy (n = 70) conducted in the primary care clinics. Treatment included education and awareness, motivational interviewing, relaxation training, cognitive therapy, exposure, problem-solving skills training, and behavioral sleep management. Patients assigned to receive EUC (n = 64) received biweekly telephone calls to ensure patient safety and provide minimal support. MAIN OUTCOME MEASURES Primary outcomes included worry severity (Penn State Worry Questionnaire) and GAD severity (GAD Severity Scale). Secondary outcomes included anxiety ratings (Hamilton Anxiety Rating Scale, Beck Anxiety Inventory), coexistent depressive symptoms (Beck Depression Inventory II), and physical/mental health quality of life (12-Item Short Form Health Survey). RESULTS Cognitive behavior therapy compared with EUC significantly improved worry severity (45.6 [95% confidence interval {CI}, 43.4-47.8] vs 54.4 [95% CI, 51.4-57.3], respectively; P < .001), depressive symptoms (10.2 [95% CI, 8.5-11.9] vs 12.8 [95% CI, 10.5-15.1], P = .02), and general mental health (49.6 [95% CI, 47.4-51.8] vs 45.3 [95% CI, 42.6-47.9], P = .008). There was no difference in GAD severity in patients receiving CBT vs those receiving EUC (8.6 [95% CI, 7.7-9.5] vs 9.9 [95% CI, 8.7-11.1], P = .19). In intention-to-treat analyses, response rates defined according to worry severity were higher following CBT compared with EUC at 3 months (40.0% [28/70] vs 21.9% [14/64], P = .02). CONCLUSIONS Compared with EUC, CBT resulted in greater improvement in worry severity, depressive symptoms, and general mental health for older patients with GAD in primary care. However, a measure of GAD severity did not indicate greater improvement with CBT. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00308724.

Psychometric properties of the Depression Anxiety and Stress Scale-21 in older primary care patients

The Depression Anxiety Stress Scale (DASS) was designed to efficiently measure the core symptoms of anxiety and depression and has demonstrated positive psychometric properties in adult samples of anxiety and depression patients and student samples. Despite these findings, the psychometric properties of the DASS remain untested in older adults, for whom the identification of efficient measures of these constructs is especially important. To determine the psychometric properties of the DASS 21-item version in older adults, we analyzed data from 222 medical patients seeking treatment to manage worry. Consistent with younger samples, a three-factor structure best fit the data. Results also indicated good internal consistency, excellent convergent validity, and good discriminative validity, especially for the Depression scale. Receiver operating curve analyses indicated that the DASS-21 predicted the diagnostic presence of generalized anxiety disorder and depression as well as other commonly used measures. These data suggest that the DASS may be used with older adults in lieu of multiple scales designed to measure similar constructs, thereby reducing participant burden and facilitating assessment in settings with limited assessment resources.

Anxiety in dementia: A critical review

Until recently, little attention has been paid to anxiety symptoms in dementia. However, anxiety is common in this population, and associated with poor outcome and quality of life. The current review examines the existing literature around three major themes: the definition of anxiety in dementia, the properties of available instruments for assessment, and the clinical characteristics of anxiety in this population. Defining anxiety in individuals with dementia is complicated by the overlap between symptoms of anxiety, depression and dementia, and by the influence of the source of information. Several instruments are available to assess anxiety in this population, including general neuropsychiatric instruments and two scales designed specifically for this purpose. The reliability of these instruments is acceptable, but their validity has not been sufficiently examined, and they may discriminate poorly between anxiety and depression. Anxiety may be higher in vascular dementia than in Alzheimers Disease, and it decreases in the severe stages of dementia. It is associated with poor quality of life and behavioral disturbances, even after controlling for depression. Little is known, however, about its social and environmental correlates. Limitations of the existing literature and key directions for future research are discussed.

Hearing impairment in older adults: new concepts.

OBJECTIVE: To review present information about the epidemiology, etiologies, pathogenesis, evaluation, and quality of life aspects of hearing loss and to present an approach to rehabilitation for hearing loss in older adults.

Healthy IDEAS: A Depression Intervention Delivered by Community-Based Case Managers Serving Older Adults

This study evaluated an evidence-based intervention for depression delivered by case managers in three community-based service agencies to high-risk, diverse older adults. Case managers were trained to provide screening and assessment, education, referral and linkage, and behavioral activation. Outcomes addressed depression, general health status, social and physical activation, and mental health services use at baseline and 6 months. Participants (n = 94) were predominantly women (79%) and Hispanic (44%), with a mean age of 72 years. Mean Geriatric Depression Scale—15 scores differed significantly between baseline and 6 months (9.0 versus 5.5). At 6 months, significantly more participants knew how to get help for depression (68% versus 93%), reported that increasing activity helped them feel better (72% versus 89%), and reported reduced pain (16% versus 45 %). The authors conclude that nonspecialty providers can be trained to successfully implement an evidence-based self-management intervention for depression with frail, high-risk, and diverse older adults.

Comparison of Conventional Amplification and an Assistive Listening Device in Elderly Persons

Objective: To assess the impact of personal amplification systems on quality of life of elderly persons and to compare conventional hearing aid with assistive listening device. Design: Audiologic, neuropsychologic, and quality‐of‐life measures were prospectively administered to 180 elderly, hearing‐impaired persons before and after randomized 6 wk trials of four treatment conditions‐a no‐amplification condition and three different types of amplification: 1) conventional hearing aid, 2) assistive listening device, and 3) a combination of the two systems. All subjects volunteered to participate in a study comparing different amplification systems and were paid for their participation. Results: Both self‐perceived handicap and speech understanding were improved significantly by all three amplification systems. There were no significant group differences between new users and previous users of amplification in self‐assessed handicap after amplification use. Anecdotally, subjects preferred the sound quality of the assistive listening device, but an overwhelming majority (97.3%) still chose the conventional aid for use in daily living. Conclusions: Results affirm the significant impact of amplification on the quality of life of elderly persons. The strong preference for the conventional hearing aid in everyday use undoubtedly reflects the fact that elderly users usually are not willing to endure the difficulties associated with the use of remote‐microphone systems.

Partners in Dementia Care: A Care Coordination Intervention for Individuals With Dementia and Their Family Caregivers

PURPOSE This article provides a detailed description of a telephone-based care coordination intervention, Partners in Dementia Care (PDC), for veterans with dementia and their family caregivers. Essential features of PDC included (a) formal partnerships between Veterans Affairs (VA) medical centers and Alzheimers Association Chapters; (b) a multidimensional assessment and treatment approach, (c) ongoing monitoring and long-term relationships with families, and (d) a computerized information system to guide service delivery and fidelity monitoring. DESIGN AND METHODS Data illustrating the use of the intervention were displayed for 93 veterans and their caregivers after 12 months in PDC. Descriptive data were provided for each major component of the intervention protocol, including: initial assessment, goals, action steps, and on-going monitoring. Care coordinators completed a 12-item questionnaire ascertaining the acceptability and feasibility of implementing PDC. RESULTS Data from the assessments and goals indicated areas of need were not limited to any one issue or subset of issues, but were widely distributed across a variety of domains. Findings for action steps suggested a primary focus on getting/giving information and action-oriented tasks to access services and programs. Most action steps were assigned and completed by veterans spouses and the majority were successfully accomplished. On average, families had two contacts per month with care coordinators. Few barriers were indicated by care coordinators in implementing PDC, highlighting the acceptability and feasibility of the PDC protocol. IMPLICATIONS PDC addressed the diverse needs of individuals with dementia and their caregivers, including important non-medical care issues, such as understanding VA benefits, accessing community resources, and addressing caregiver strain. PDC proved to be a feasible model that was complementary to the existing programs of the 2 partnering organizations.

Can paraprofessionals deliver cognitive-behavioral therapy to treat anxiety and depressive symptoms?

Many studies support the effectiveness of paraprofessionals in administering psychotherapy. However, no review has compared the utility/efficacy of paraprofessionals versus professionals in administering cognitive-behavioral therapies (CBT). This article systematically reviews published trials comparing outcomes of paraprofessional to professional therapists using CBT to treat anxiety and depressive symptoms. Four studies met inclusion criteria and are critiqued using evidence-based quality parameters. The authors conclude that paraprofessionals can be effective in delivering CBT to these patients, with outcomes comparable to those of professionals.

Cognitive-behavioral treatment for anxiety in patients with dementia: two case studies.

Anxiety is common in dementia and is associated with decreased independence and increased risk of nursing home placement. However, little is known about the treatment of anxiety in dementia. This article reports results from two patients who were treated with a modified version of cognitive-behavioral therapy for anxiety in dementia (CBT-AD). Modifications were made in the content, structure, and learning strategies of CBT to adapt skills to the cognitive limitations of these patients and include collaterals (i.e., family members, friends, or other caregivers) in the treatment process. The patients received education and awareness training and were taught the skills of diaphragmatic breathing, coping self-statements, exposure, and behavioral activation. The Clinical Dementia Rating (CDR) Scale was used to characterize dementia severity and determine eligibility for treatment (a CDR score of 0.5 to 2.0 was required for participation). Other measures included the Rating Anxiety in Dementia scale, the Neuropsychiatric Inventory Anxiety subscale, and the Mini International Neuropsychiatric Interview. Outcome data showed improvement in anxiety as measured by standardized rating scales. We conclude that CBT-AD is potentially useful in treating anxiety in dementia patients and that this technique merits further study.

LAY PROVIDERS CAN DELIVER EFFECTIVE COGNITIVE BEHAVIOR THERAPY FOR OLDER ADULTS WITH GENERALIZED ANXIETY DISORDER: A RANDOMIZED TRIAL

The Institute of Medicine recommends developing a broader workforce of mental health providers, including nontraditional providers, to expand services for older adults. Cognitive behavior therapy (CBT) is effective for late‐life generalized anxiety disorder (GAD), but no study has examined outcomes with delivery by lay providers working under the supervision of licensed providers. The current study examined the effects of CBT delivered by lay, bachelor‐level providers (BLP) relative to Ph.D.‐level expert providers (PLP), and usual care (UC) in older adults with GAD.