Working with Older Adults: IAPT core training for High Intensity Therapists and PWPs
Pre-Training Reading and Resource Pack Day 1: Information and overview of key issues when working with older people (attended by all HIs and PWPs)
Day 2/3: Assessment, formulation, intervention and endings when working with older people (1 day for HI CBT Therapists and 1 for PWPs)
Funded By South Central SHA
This two day course will allow you to:
Think about your own attitudes towards ageing and later life and understand how these may impact on therapy Understand what types of cognitive change occur as we age Understand key information around dementia, depression and anxiety in older age To raise awareness of key screening tools used to assess mood disorders and how to raise the issue of memory difficulties with older people Gain information on key psychological interventions which are effective for older people Think about your own IAPT service and consider how you can make it more accessible and effective for older people
Legal Disclaimer: The authors are not responsible for errors or omissions or for any consequences arising from the information in this pack and make no warranty, express or implied with respect to its contents. Authors This has been a joint project written and adapted by the following authors: Dr Fionnuala McKiernan – University of Southampton Alison Gold – University of Southampton Dr Candy Stone – Oxford Health NHS Foundation Trust This train the trainer pack has been funded by South Central SHA. Thanks to Ineke Powell IAPT lead and GP commissioning development lead NHS South of England, for her role in initiating and overseeing the project. It has been coordinated by Dr John Pimm (Regional IAPT lead) and Dr Colin Hicks (Lead for Older People). We would like to thank colleagues who have commented on this draft and/ or have allowed for their work to inform this training pack. These people include Ken Laidlaw, Marie Claire Shankland, Ian James and Steve Boddington. Thanks also to the following people who have contributed to this project: Dr Suzie Harrison (Health Minds, Bucks IAPT services), Shona Lavey (Trainee Clinical Psychologist, Oxford University Doctoral Clinical course), Vivienne Purcell (Talking Space, Oxfordshire IAPT services, Harriet Barlow (Oxford Health NHS Foundation Trust), Elizabeth Kemp (Oxford Health NHS Foundation Trust). 2
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Contents Page:
Page Number
Day 1: Module 1 Attitudes towards ageing and later life including Psychological models
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Fact sheet on older people Events in History useful for working with older people
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Module 2: Reading list on Caring
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Outcome of Psychological Interventions
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Module 3: Steve Boddington Bench Marking tool
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Module 4: Screening and assessing mood disorders and memory deficits in older people
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Day 2: Selection, Optimisation and Compensation (SOC) model
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CBT Conceptual Framework for Older People (Laidlaw, 2004)
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References
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Day 1: Module 1 Attitudes towards ageing and later life We spend a lot of time in the course thinking about our own personal attitudes towards aging. We also discuss current research related to this and draw upon relevant psychological models. The following background information may be of interest to read prior to training: a) Erikson (1959;1982) Erikson’s theory of personality development includes eight stages which he suggests all people will go through. Each stage is a ‘psychosocial crisis’ which requires resolution for personality to continue develop. These stages often relate to a person’s interaction with the world and others around them. Erikson hypothesised that a failure at any stage leads to psychological difficulties and would prevent progression to the next stage. The eight and final stage, thought to relate to adults 60 years and above, is “Ego Integrity vs. Despair”. This stage is proposed to occur when an individual develops a sense of their own mortality. This prompts the ‘crisis’, in the form of a review of the individual’s life to determine whether it was a success or failure. Ego integrity is thought to be a sense of satisfaction or contentment with one’s life, whereas despair is caused by either a sense of dissatisfaction with one’s life, or not resolving the ‘crisis’ by failing to determine if one’s life was successful or not. Erikson states that ego integrity leads to contentment with life, wisdom, and pride, even in the face of death. However, if the outcome of the crisis is despair, then it is thought an individual will experience fear of death, regrets, a sense that life is too short, and depression. b) Activity theory of ageing Cavan, Burgess, Havighurst, & Coldhamer (1949) developed the activity theory of ageing to explain why some older people were happy and satisfied with their lives, and others were not. It is thought that an individual’s life satisfaction is directly linked to their participation in social activity. This is based on the theory that older people have the same psychological and social needs as middle aged people, and it is only biology and health which to differentiate these two groups. Changes in the social opportunities an older person has (such as through enforced retirement or declining health) can lead to a decrease in activity and engagement with the environment. This may lead to a gradual loss of self esteem and an increased sense of disengagement (Maddox & Eisdorfer, 1962). However, in line with the theory that people have the same psychological and social needs in middle and older age, this means that an individual’s activity in older adulthood should reflect the level of activity which gave them satisfaction in middle adulthood. Knapp (1977) found that generally, older people surveyed 4
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in the UK with higher levels of activity expressed higher levels of positive affect than those with low levels of activity.
c) Knight’s (2004) Contextual Cohort Maturity Specific Challenge Model (CCMSC) This model provides a framework to adapt interventions originally designed for the adult population to be more suitable for older people. It draws on two models of ageing, a loss deficit model and an age cohort period model. The contextual cohort components of the CCMSC focuses on the understanding of the impact of cohort into which people are born, sociohistorical factors and the social environment on the older person’s well being. The maturation component considers the physical, cognitive and psychological aspects of age related declines. The specific challenge component reflects on the particular age related issues that older people face. To accommodate a cultural context into the model, the CCMSC was revised in 2008 by Knight and became the contextual adult lifespan theory for adapting psychotherapy (CALTAP). The model is given below:
For more information on the CALTAP model please see references at the end of this precourse document. 5
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IAPT Resource pack Day 1: Fact sheet In the teaching you will be presented with some facts about older people. Here are a few more. Look at the following facts and take a minute to make a guess of the answers:
What percentage of people aged 65-74 is involved in formal volunteering? How many people in the UK aged over 65 were estimated to be suffering from dementia in 2010? What percentage of the over 65s said that they never felt lonely in the last two weeks? How many people aged 65 and over were in paid employment between January – March 2012? How many people aged over 65 are providing unpaid care for a partner, family or others? What percentage of older people with depression does the Royal College of Psychiatrists estimate receive no help at all from the NHS? How many pensioners live below the poverty line (less than £215 a week after housing costs)? What percentage of people aged 70 and over has a mobility difficulty? What percentage of older people have less than weekly contact with family, friends and neighbours? Data from
[email protected] monthly factsheet November 2012
Look at the next page for facts (last updated Nov 2012)
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Fact Sheet – the answers: What percentage of people aged 65-74 is involved in formal volunteering? 31% How many people in the UK aged over 65 were estimated to be suffering from dementia in 2010? 820,000 What percentage of the over 65s said that they never felt lonely in the last two weeks? 70% How many people aged 65 and over were in paid employment between January – March 2012? .9 million How many people aged over 65 are providing unpaid care for a partner, family or others? 960,000 What percentage of older people with depression does the Royal College of Psychiatrists estimate receive no help at all from the NHS? 85% How many pensioners live below the poverty line (less than £215 a week after housing costs)? 1.7 million What percentage of people aged 70 and over has a mobility difficulty? 38% What percentage of older people have less than weekly contact with family, friends and neighbours? 17% Data from
[email protected] monthly factsheet November 2012
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Events in History useful for working with older people Chronological history 1910 1912 Titanic sank 1914 First World war starts 1918 End of First WW 1920 1926 General Strike 1929 Great Crash 1930 1934 Great Depression 1936 Spanish Civil war 1939 Start of Second World War 1940 Churchill comes to power, start of Battle of Britain, Dunkirk 1941 Japanese attack on Pearl Harbour 1944 D Day 1945 VE day declared May 8th Hiroshima ‐ Atomic bomb dropped August 6th 1950 Korean War 1953 Coronation of Queen Elizabeth II; Ascent of Everest 1960 8
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1961 Introduction of contraceptive Pill 1963 Cuban Crisis 1966 England won World Cup 1967 Homosexuality legalised 1969 First man on the moon 1970 1971 Decimalisation 1977 Queen’s Silver Jubilee 1980 1982 Falklands War
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Module 2: Carers Books that may be useful to read yourself as a therapist or recommend to others. The selfish pig’s guide to caring – Hugh Marriort Keeping Mum – caring for someone with dementia. –Marianne Talbot Still Alice – Lisa Genova Contented Dementia – Oliver James
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Module 2: Outcome of Psychological Interventions There is a strong evidence base that psychological interventions are useful for older people. The studies below expand on this. •
Cochrane Review (Wilson et al 2008) •
limited number of good quality studies (7 CBT/2 psychodynamic)
•
CBT effective compared with active & waiting list controls
•
Laidlaw et al, 2008 – CBT without medication is an effective treatment for late life depression and superior to Treatment as Usual (TAU) for reducing hopelessness
•
Serfaty et al, 2009, 2011 - compared TAU, talking +TAU and CBT +TAU and found CBT+ TAU significantly more effective.
In the first UK evaluation of individual CBT for late-life depression in primary care, Laidlaw et al., (2008), randomly allocated 114/44 participants to one of two treatment conditions; CBT alone or treatment as usual (TAU). In the TAU condition, older participants received the range of treatments they would ordinarily receive in primary care, without external influence or pressure. Laidlaw et al., (2008) reported benefits in depression outcome for CBT alone and TAU, at the end of treatment and at six months follow-up. However, after taking account of baseline scores between the groups, a significant difference in outcome emerged, with participants in the CBT treatment group recording significantly lower scores on the Beck Hopelessness Scale (which measures optimism and pessimism) at six months after the end of treatment, compared with participants in the TAU group. Moreover, significant differences favouring CBT also emerged on evaluation of the number of participants who remained depressed according to Research Diagnostic Categorisation (RDC) status (a way of systematically agreeing symptom level measures of depression) at the end of treatment and at three months follow-up. Thus although the study was small, and the levels of depression mild, the findings suggest that CBT by itself (participants who received this treatment did not also receive medication) is an effective treatment for late-life depression. This study remains one of the very few to compare the efficacy of psychological treatment with treatment usually offered in primary care, and one of the very few that has systematically measured the effectiveness of CBT as a treatment in a non-medicated treatment group. A more recent study, carried out by Serfaty et al., (2009; 2011), provides further compelling evidence for CBT as an efficacious treatment for late-life depression in primary care. This study compared CBT plus TAU, a talking control 11
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condition plus TAU, and TAU alone. CBT participants on average achieved better treatment outcomes compared to the talking control condition and TAU, with 33 per cent of those receiving CBT recording a 50 per cent or greater reduction in Beck Depression Inventory (BDI) scores, compared to 23 per cent and 21 per cent, respectively, for those receiving TAU and The talking control treatment. Importantly, Serfaty et al (2009) conclude their results discredit the myth that depressed older people are lonely and simply need a listening ear, as those in the talking control group did less well than those in the CBT treatment group.
Day 1: Module 3 Local services for Older People We spend time in the training discussing what services are available for older people within your local areas. To help facilitate this task, we are asking attendees to please briefly research what services are available for older people in your county. This information will be discussed in small groups on the teaching day. Please bring any notes and resources to share with your colleagues. In particular, we would like you to include: 1. Voluntary/third sector services (e.g. Age UK, Alzheimer’s Society, volunteer organisations, U3A) 2. Dementia services, including: ‐ where to refer for diagnosis (e.g. memory clinics) ‐ day services for people with Dementia ‐ Support groups/services for carers Please note – there can be a huge range of services for older people, we do not need you to gather an abundance of information, rather a flavour of what services are available in your county. We are hoping that within each small group there will be a local Older Person’s Psychologist/Specialist who may be able to provide further information for the group. To help with your information gathering, we recommend the following websites: www.dementiaweb.org Local NHS Trust and County Council websites Age UK Alzheimer’s Society
Bench Marking Tool 12
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How effective are our IAPT services at engaging and working with older people? We also spend time in training thinking about how effective our own services are at working with older people. Please spend some time briefly looking through the following benchmarking tool which highlights the ‘gold standard’ for how IAPT services should ideally be working with older people. Select three areas/points and consider how your service currently operates and any adaptation/ improvements which could be made This tool is provided as part of the teaching. Please look at it and give it some thought. You will be asked to complete some of it on day 1.
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Is your IAPT Services accessible to older people? With permission from Steve Boddington
Service:
Rater/s:
Date:
Aspect of service design:
Existing actions that already facilitate older people’s access:
Further actions that could be adopted to improve your service:
Equity of Access Targets:
1
- What proportion of your services referrals is currently over 65 years old? - does this reflect your local demographic – on average there should be 18% referrals over 65years but varies locally
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Does your service undertake ongoing publicity to attract older adults referrals?
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In general GPs are poor at recognising common mental disorders in later life and seldom refer older people for psychological therapy. The 3rd sector, acute services and OP themselves also need to be targeted. Repeated and persistent publicity helps to resolve this pattern.
Modified ‘engagement/filtering’ procedures for getting into your service.
3
Older people may be reluctant to opt into psychological services due to: 1. Being unfamiliar with ‘psychological treatments’ 2. having internalised ageist ideas about their value/ability to change 3. Mobility/health problems 4. Higher levels of agoraphobia
Offer home visits if necessary:
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- A small proportion of older people will not
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be able to attend clinics due to mobility problems, visual impairments, agoraphobia, etc. - Sometimes an initial home visit may be all that is needed to break down reticence and encourage attendance at clinic/telephone appointments after that.
Offer help to complete IAPT forms where necessary:
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1.People may be out of practice at form filling. 2Psychological language may be unfamiliar 3There is a higher level of literacy problems amongst older people as educational opportunities were less equally available 60+ years ago. 4 Mild Cognitive Impairment may affect ability to concentrate/focus.
Capacity to adjust the pace, length, frequency of sessions where necessary
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- Can your therapists offer longer or
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shorter appointments to accommodate the needs of the patient? - Can appointments be scheduled more/less frequently? - Can additional sessions be offered for patients who’s progress is slow?
Do you have a resource for signposting to age-appropriate services?
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e.g. Alzheimer’s Soc, sitting services, Carer’s Centre, Age –UK
Is this up to date? Are your staff trained to work with older people?
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- Have all therapists (HI & PWP) received the 2 day training in applying their therapeutic skills to older people? - Do some of your staff have a special interest in such work (with appropriate additional training?)
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Do some IAPT staff with a special interest undertake supervision of OP cases seen by all IAPT staff?
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- This ensures that older people do not get overlooked and may be seen by therapists with an interest/knowledge/ skill in working with the client group
Are there arrangements for specialist supervision/ consultation from specialists working with older people?
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- Arrange this with secondary care therapists specialising in work with older people
Referral to vocational/educational/occupational services:
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- These should be set up to meet the needs of older people: opportunities for voluntary work, engagement in local community resources/activities. eg – computer classes for older people
Be aware of possible cognitive limitations in older adults, and how
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they impact on therapy: - Develop effective links with local memory services
How effective are the referral pathways between your IAPT service and the Secondary Mental Health services for older people?
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1. Do you know the Psychologists/ Psychological therapists who specialise in working with older people in your area? -2. How often do you escalate referrals to secondary care? 3. How often does your service receive referrals of older people with common mental health problems from CMHTs?
Is there an older person on your service user group?
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- Active involvement of older service users will help to ensure that the service attends
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to the needs of older people - Older service users may have knowledge and experience of local resources that can help IAPT to integrate with wider network of health and social care
S.Boddington
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Day 1: Module 4 Screening and assessing mood disorders and memory deficits in older people We spend part of the training discussing how we assess mood disorders and memory decline within older people. It may be helpful to familiarise yourself with the following measures prior to training. It should be noted that you will not be required to screen for memory problems using these tools – they are presented for your information and understanding only. Agree with this
a) Mini Mental State Examination (MMSE) – a cognitive functioning screening tool traditionally used by OA CMHTs to diagnose MCI/Dementia. Scores > 27 (out of 30) considered normal. b) The Montreal Cognitive Assessment (MOCA) – an alternative, more sensitive screening tool, which also assesses executive dysfunction. Scores > 27 considered normal. Follow the link to look at the tool. There may be one available to view at the training day. www.mocatest.org c) Geriatric Depression Scale (GDS) – a brief 5 item measure sensitive at detecting depression with older people. Easy to complete. Can be used as an addition to the MDS. Considerations at a higher level are currently being decided as to whether we can use this scale as alternative to MDS rather than an addition.
Item 1. Are you basically satisfied with your life? 2. Do you often get bored? 3. Do you often feel helpless? 4. Do you prefer to stay at home rather than going out and doing new things? 5. Do you feel pretty worthless the way you are now?
Circle one YES NO YES NO YES NO YES NO YES
NO
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d) Geriatric Anxiety Inventory 5 (GAI 5) This five point version of the geriatric anxiety scale is a useful addition to screening tools for anxiety. Three or more agreed with items suggest that the person may be experiencing GAD.
d) Hospital Anxiety and Depression Scale
Day 2 High Intensity workers and PWPS: e) The Hospital Anxiety and Depression Scale (HADS) This is a useful measure for older people because it separates out anxiety and depression and includes physical health. It is widely available and a reference can be found in the references section. It is copyrighted so may only be used if purchased by the service.
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Selective Optimisation Compensation Model (SOC) (Baltes & Baltes, 1990) This is a theory which represents a dialectical life span approach. Although we experience gains and losses throughout the life span we are especially burdened with losses in later life. The SOC model is a way in which people can successfully age. Laidlaw et al (2004) applies this model to allow an individual to maximise their functioning and at the same time minimising the impact of loss experiences. The SOC model has three main components: selection, optimisation and compensation. This model acknowledges that older people faced with a challenge such as illness, can still use CBT to select a goal. They then need to optimise their levels of functioning by focusing resources to achieve their goal. It may mean that the individual has to relearn to adjust to a reduced level of activities. They then compensate by taking account of limitations and engaging in alternative means to achieve maximum functioning. This model is discussed in more detail in “Cognitive behaviour therapy with depressed older people” Ken Laidlaw and Larry W. Thompson a chapter in handbook of emotional disorders in later life (See reference list).
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CBT Conceptual Framework for Older People (Laidlaw et al 2004) This model is a CBT formulation model that is valuable to aid the therapists thinking rather than share with a client. For more reading about this model see Ian James’ Book Cognitive Behaviour Therapy with Older People in reference list.
Th e core sec tion of the form ulatio n is the cla ssic B e ckian mo del. A ddition ally to this, the rapists are adv ise d to c onside r the follo wing : Cohort B eliefs: Th e spec ific v iews an ind ivid ual ma y h old as a c onseq uence o f being born and g ro wing up in a certa in time p eriod. The se may b eliefs as soc iated with age ing (h ow a person is sup posed to ‘do’ age in g), w hat it m ay mean to have a ‘ps ych ologic al prob le m’ o r how one s hould d eal w ith e motio ns (e.g . ‘stiff u pper lip’). Transitions in role inve stm ents: Th e pos sible c hanges a person ma y be going through related to their role, for e xamp le retirem ent, bereavem ent, becom ing a great grand parent. Ph ysical He alth: A ny ch anges or dete rio rations to hea lth, an d the mean in g and impa ct thes e have . So ciocultura l context: The iden tity a p erson has within their cu lture and env iro nment; h ow th eir c lass and politic s m ay hav e a ro le in their c urrent presen tation.
Intergene rationa l linka ge s: Th e netw orks , s upports and relatio nship s the indiv idua l h as within their c ommu nity and within the ir fam ily , a ny tens ions or ongoin g dilem mas or disag reemen ts with in the se relat ionsh ips
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Suggested reading list Blazer, D.G. (2010) Protection from depression. International Psychogeriatrics, 22, pp. 171-173. Boddington, S. (2011) Where are all the older people? Equality of access to IAPT services, PSIGE Newsletter, 113, pp. 11-14. Broomfield, N.M., Laidlaw, K., Hickabottom, E., Murray, M. F. Pendrey, R., Whittick, J.E. and Gillespie, D.C. (2011) Post-Stroke Depression: The Case for Augmented, Individually Tailored Cognitive Behavioural Therapy, Clinical Psychology and Psychotherapy,18, 202–217 (2011) Cartensen, L., Turan, B., Scheibe, S., Ram, N., Erser-Hershfeld, H., Samanez-Larkin, G., Brooks, K. P., Nesselroade, J.R., (2011) Emotional experience improves with age: Evidence based on over 10 years of experience sampling. Psychology and Aging,26, 21-33. Charles, S.T. & Carstensen, L.L. Social and emotional aging, Annual Review of Psychology, 2009; 61, pp. 383-409. Freund, A. M. & Baltes, P. B. (1998) Selection, optimization, and compensation as strategies of life management: Correlations with subjective indicators of successful aging. Psychology and Aging, 13, pp. 531-543. Garner, J. (2002) Psychodynamic work with older adults.. Advances in Psychiatric Treatment, 8, pp. 128-135 Gorsuch, Nikki (1998) Times winged Chariot: Short term psychotherapy in later life. Psychodynamic Counselling 4 (2) pp. 191-202 James, Ian Andrew (2010) Cognitive Behavioural Therapy with Older People: Interventions for those with and without Dementia, Jessica Kingsley Publishers, London Knight, B. G. (2004) Psychotherapy with Older Adults, 3rd Edition. Thousand Oaks: Sage Publications Laidlaw,K., & Knight, B.G. (Eds.) (2008) Handbook of Emotional Disorders in Later Life. Oxford:OUP Laidlaw, K., Thompson, L.W. & Gallagher-Thompson, D. (2004) Comprehensive Conceptualization Of Cognitive Behaviour Therapy For Late Life Depression, Behavioural and Cognitive Psychotherapy, 2004, 32, 1–11 Laidlaw, K. & McAlpine, S. (2008) Cognitive Behaviour Therapy: How is it Different with Older People? J Rat-Emo Cognitive-Behav. Ther. Laidlaw, K. & Pachana, N.A.(2009) Aging, Mental Health, and Demographic Change: Challenges for Psychotherapists, Professional Psychology: Research and Practice © 2009 American Psychological Association, 2009, Vol. 40, No. 6, 601–608 25
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Laidlaw, K., Thompson, L.W., Siskin-Dick, L. & Gallagher-Thompson, D. (2003) Cognitive Behavioural Therapy with Older People. Chichester: John Wiley & Sons, Ltd. ISBN 978-0-47111-1 Laidlaw, K, (2010) Enhancing Cognitive Behaviour Therapy with Older People using Gerontological theories as Vehicles for Change, in, Pachana, N.A. Laidlaw, K. & Knight, B. G. (Eds.) Casebook of Clinical Geropsychology: International Perspectives on Practice. Oxford: OUP. Sadavoy, J. (2009) An integrated model for defining the scope of psychogeriatrics: The five Cs. International Psychogeriatrics, 21, pp. 805-812.
Additional References: Byrne,J.G. and Pachana, N.A. (2010). Development and validation of a short form of the Geriatric Anxiety Inventory –the GAI-SF. International Psychogeriatrics. doi:10.1017/S1041610210001237. Available free via GAI website Cavan, R.S., Burgess, E.W., Havighurst, R.J., & Goldhamer, H. (1949) Personal adjustment in old age. Science Research Associates, Chicago. Erikson, E. (1959) Identity and the Life Cycle. New York: International University Press Knapp, M. R. J. (1977) The Activity Theory of Aging An Examination in the English Context. The Gerontologist 17(6), 553-559 Maddox, C, & Eisdorfer, C. (1962) Some correlates of activity and morale among the elderly. Social Forces, 41, 254-260 Zigmond, A.S. & Snaith, R. P. (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavia, 67, 361 – 370.
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