Modifying treatment for mildly Modifying treatment for mildly impaired older adults.impaired older adults.

Felton Institute Felton Institute

December 6, 2007December 6, 2007

Patricia A. Arean, PhDPatricia A. Arean, PhD

The Over 60 ProgramThe Over 60 Program

Department of Psychiatry, UCSFDepartment of Psychiatry, UCSF

Learning ObjectivesLearning Objectives

Understand the influences of Understand the influences of cognitive impairment on practicecognitive impairment on practice

Recognize behaviorally when Recognize behaviorally when cognitive issues may be importantcognitive issues may be important

Tailor your work with these patients Tailor your work with these patients using some easy strategies (using using some easy strategies (using psychotherapy as an example).psychotherapy as an example).

Mild Cognitive Impairment Mild Cognitive Impairment (revisited)(revisited)

Cognitive Impairment:Cognitive Impairment:– Not just memoryNot just memory– Executive dysfunctionExecutive dysfunction– Language impairmentLanguage impairment– Attention Attention – Information processing speedInformation processing speed

30% to 70% co-occurrence with mental 30% to 70% co-occurrence with mental illnessillness

Often under recognizedOften under recognized Can influence treatment outcomesCan influence treatment outcomes

Mr. KMr. K 79 year old middle eastern man;79 year old middle eastern man; MMSE = 29MMSE = 29 Well groomed, very well dressed, no beltWell groomed, very well dressed, no belt Complains of losing common items around Complains of losing common items around

house and at workhouse and at work Very tearful, sudden onset, cannot tie to Very tearful, sudden onset, cannot tie to

any triggerany trigger Missed entire column on BDIMissed entire column on BDI Narrative often goes off track, forgets Narrative often goes off track, forgets

questions asked of him, but remembers on questions asked of him, but remembers on cuing.cuing.

Mrs. QMrs. Q

84 year old woman;84 year old woman; MMSE = 30;MMSE = 30; Depressed after daughter moved Depressed after daughter moved

from town;from town; Increased clutter in home;Increased clutter in home; Slightly disheveled in appearance;Slightly disheveled in appearance; Stopped many activities.Stopped many activities.

PsychotherapyPsychotherapy

How psychotherapy works…How psychotherapy works…

Psycho-education;Psycho-education; Reframing past and current Reframing past and current

experiences from negativistic to experiences from negativistic to balanced/rational perspectives;balanced/rational perspectives;

Mood induction;Mood induction; Resolve problems causing Resolve problems causing

depression.depression.

Cognitive skills needed to make psychotherapy Cognitive skills needed to make psychotherapy work…work…

Recall and recognition;Recall and recognition; Attention and working memory;Attention and working memory; Speed of information processing;Speed of information processing; Problem solving skill;Problem solving skill; Mental/cognitive flexibility;Mental/cognitive flexibility; Expressive and receptive language.Expressive and receptive language.

Recall and recognitionRecall and recognition

Depends on causes of memory Depends on causes of memory impairments;impairments;

Cued recall approachesCued recall approaches– Sequenced retrieval;Sequenced retrieval;– Paired learning;Paired learning;– Environmental promptsEnvironmental prompts

Life review techniquesLife review techniques

Attention and working memoryAttention and working memory

Shorter sessions;Shorter sessions; Timing of sessions (am versus pm);Timing of sessions (am versus pm); ““Cue and review”;Cue and review”; Socratic questioning.Socratic questioning.

Speed of information processingSpeed of information processing

One problem at a time;One problem at a time; Cue and review;Cue and review; More sessions over time.More sessions over time.

Problem solving skillProblem solving skill

Targeted interventionsTargeted interventions Action planningAction planning Brain storming techniquesBrain storming techniques PromptingPrompting

Expressive and receptive language.Expressive and receptive language.

Behavioral activation;Behavioral activation; Simple, common terms;Simple, common terms; Tie complex terms to familiar terms;Tie complex terms to familiar terms;

Symbols don’t always work.Symbols don’t always work.