fewer hospitalizations at six‐month follow‐up (Freedland, et al., 2015). Even in the setting of acute medical illness, CBT for late‐life depression has been found effective in reducing depression symptoms and improving physical functioning at four‐month follow‐up relative to waitlist controls (Hummel, et al., 2017).
Several therapies have been adapted for specific patient populations to address the presentation of depression with comorbid medical conditions. For example, Personalized Adherence Intervention for Depression with Severe COPD (PID‐C) was developed to address depression in COPD with a course of nine sessions (Sirey, Raue, & Alexopoulos, 2007; Alexopoulos, et al., 2013; Alexopoulos, et al., 2016). This intervention focuses on identifying treatment (medical, rehabilitation, psychiatric) adherence barriers and using targeted strategies involving psychoeducation and support to address and overcome those barriers. Randomized controlled trials of PID‐C, as well as the incorporation of PID‐C with PST, resulted in higher remission rates of depressive symptoms and dyspnea‐related disability compared to those receiving treatment as usual. In a systematic review of CBT therapies for older adults with depression and cognitive impairment, PST was found to significantly improve mood and overall disability (Simon, Cordás, & Bottino, 2015). Problem adaptation therapy (PATH) is another therapy modality with empirical support for treating depression in patients with more significant cognitive impairment (Kiosses, et al., 2015). The PATH intervention is delivered in the patient’s home over a 12‐week course, focusing on emotion regulation and reducing negative emotions associated with functional and cognitive limitations.
More generally, a behavioural conceptualization of depression in older adults with dementia can be utilized to appreciate the impact of cognitive impairment on the ability to engage in fulfilling aspects of life and the resultant increases in isolation and social withdrawal. With increased isolation and reduced opportunities for joyful activities, the individual may become more despondent or anxious. Ultimately the elevated psychiatric symptoms serve as an additional barrier to engaging in positive activities, resulting in continued isolation and worsening psychiatric status. Behavioural interventions are strategies used to disrupt that cycle by identifying and reinforcing behaviour associated with positive mood and changing the caregiver–care recipient relationship to reinforce and maintain those positive behaviours (Logsdon, McCurry, & Teri, 2007). In individuals with significant cognitive impairment with or without behavioural disturbance, behavioural interventions may be as basic as maintaining a routine (e.g. consistent bedtime and waking hours) to limit day/night confusion, or they may be more complex and require integration of observed disturbances with the person’s life history. McConnell (2014) provides a case example of utilizing behavioural intervention in a patient with moderate dementia who began to experience sleep disturbance and agitation after placement of devices on his feet to prevent pressure ulcers. The disturbed behaviour was incorporated with the patient’s history of having been a prisoner of war; the medical devices, although intended to help the patient, may have been a trigger for feelings of confinement that led to agitation. As such, disrupting that negative cycle required eliminating the behaviour reinforcer (devices on the patient’s feet) and utilizing a more patient‐appropriate approach (pillows at the end of the bed), which resulted in a reduction of the problematic behaviour.
Non‐pharmacologic interventions for cognitive decline
Given the expected increase in the prevalence of MCI and dementia and the significant personal and societal costs of this spectrum of disorders, there is ongoing interest in identifying effective interventions for these conditions. Currently available interventions can be divided into pharmacologic and non‐pharmacologic categories. A thorough review of pharmacologic interventions is beyond the scope of this chapter, but commonly used agents include acetylcholinesterase inhibitors (e.g. donepezil) and NMDA receptor antagonists (e.g. memantine). Regardless, even when pharmacologic intervention is used, there is usually still a need for non‐pharmacologic approaches in the treatment and management of cognitive and functional decline. A past literature review suggested that non‐pharmacologic interventions for MCI and dementia can essentially be divided into four categories: (i) restorative cognitive training, (ii) compensatory cognitive training, (iii) lifestyle interventions, and (iv) psychotherapeutic interventions (Huckans, et al., 2013). The primary difference between these intervention categories is the identified target of intervention (e.g. specific symptoms versus underlying brain pathology).
Restorative cognitive training refers to interventions involving structured and repeated practice of specific cognitive tasks and mental exercises to improve specific cognitive abilities and underlying neural connections. Examples of restorative cognitive training include repetitive auditory processing training exercises or use of commercially available ‘brain training’ products. The purported target of such interventions is the neural systems underlying the cognitive domain of interest. Two assumptions underlie restorative cognitive training. The first is that practice in the given task/exercise will improve or at least maintain function in the targeted cognitive domain by way of strengthening or maintaining connectivity of underlying neural circuits. Second, it is assumed that benefits obtained from the task/exercise will generalize to behaviour outside of the training context.
Compensatory cognitive training refers to interventions that teach patients and caregivers to use specific techniques and strategies to compensate for the functional impact of cognitive deficits in daily life. The target of these interventions is improving the individual's functional ability but not necessarily underlying neural function. The primary assumption underlying this approach is that the patient, despite having cognitive deficit, can still use residual cognitive ability in impaired and unimpaired domains to learn and implement compensatory techniques. A wide variety of compensatory cognitive techniques have been described and can be subdivided into internal strategies (e.g. spaced retrieval, method of loci), external strategies (e.g. day planners, pill boxes, smartphone applications), and environmental strategies (e.g. quiet workspace, eliminating unnecessary distractions).
Lifestyle interventions refer to efforts designed to educate and promote healthy lifestyle habits that have been shown to benefit cognitive function in older adults. These interventions often target cerebrovascular health but can also target mood symptoms. Examples include education about the neuroprotective effects of regular aerobic exercise, a healthy diet, and participation in cognitively stimulating activities. Education can also focus on the detrimental effects of specific lifestyle habits, such as smoking and heavy alcohol consumption. Lifestyle interventions sometimes go beyond education and enrol individuals in exercise programs and use motivational interviewing techniques to facilitate behaviour change.
Finally, psychotherapeutic interventions refer to traditional psychotherapy approaches to target neuropsychiatric symptoms that can occur with or independent of cognitive dysfunction in older adults (e.g. depression, anxiety, sleep problems). Individuals with depression often have a greater subjective experience of cognitive symptoms than non‐depressed individuals. Treatment of mood symptoms with psychotherapy can result in improved self‐perception of cognitive and daily function. Common examples of psychotherapeutic interventions include cognitive behavioural therapy, mindfulness training, and relaxation techniques.
There is now a broad literature on the efficacy of non‐pharmacologic interventions for cognitive and functional decline in late life, and recent reviews and meta‐analytic studies have outlined the main findings of this work to date. These summaries have generally concluded that restorative cognitive training, compensatory cognitive training, and lifestyle interventions (e.g. regular aerobic exercise, dietary changes) are effective for improving cognitive function on objective neuropsychological testing as well as for improving subjective cognitive appraisal and daily function (Chandler, Parks, Marsiske, Rotblatt, & Smith, 2016); (Huckans, et al., 2013); (Sherman, Mauser, Nuno, & Sherzai, 2017). Given the broad support for these interventions, some clinics have combined these non‐pharmacologic methods with traditional pharmacologic approaches in comprehensive multidisciplinary treatment programs. One such example is the Healthy Action to Benefit Independence & Thinking (HABIT) program hosted at the Mayo Clinic.
Implications for practice
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