such as Parkinson’s disease. The presence of psychosis in dementia is high, with more than 50% of patients with probable Alzheimer’s disease displaying psychotic symptoms at some point during the disease course (Targum, 2001). Often complicating caregiving, persecutory delusions were found in 30% of patients with Alzheimer’s disease and 40% of patients with multi‐infarct dementia (Cummings, Miller, Hill, & Neshkes, 1987). Accurate diagnosis of the underlying cause of the psychosis is of utmost importance, as the identification of the medico‐neurological, psychiatric, or medication causes will ultimately guide treatment and/or behavioural management strategies.
Cognition is viewed as a key to successful ageing by patients and clinicians alike. Recent guidelines for screening of cognitive impairment in older age were published by the International Association of Gerontology and Geriatrics (IAGG) in response to the under‐detection and ‐documenting of an estimated nearly 50% of patients with some degree of cognitive impairment (Morley, et al., 2015). Detection is key, as cognitive impairment may substantially impact the course and nature of clinical care provided and the need for services to ensure health and safety that otherwise may not be considered. This is especially pressing when considering that medical comorbidities increase with age, as does the risk for cognitive decline. An illustration of the importance of understanding the relative degree of cognitive change can be seen in the scenario of older adults with diabetes and comorbid cognitive impairment. Successful management of diabetes requires insight to perform proper self‐care coordination, planning for glucose monitoring, medication and insulin management, and adherence to diet and exercise regimens. Individuals with memory problems may forget medications, insulin injections, glucose monitoring, and follow‐up appointments. Understanding how cognitive impairment may impact successful treatment is essential for developing strategies to improve disease management (e.g. use pillboxes and medication alarms, have pharmacy pack medications for each day) and identifying areas where a caregiver may need to provide aid or oversight. Insel, Morrow, Brewer, and Figueredo (2006) have identified that adherence to and independent management of medication is associated with executive functioning and working memory; when an individual’s abilities in those areas are reduced or impaired, substantial adherence problems may result. Understanding the potential impact of cognitive deficits on medication adherence may require the treating physician to simplify medication regimens and educate caregivers of the need for oversight of medications (Arlt, Lindner, Rösler, & von Renteln‐Kruse, 2008).
Psychological interventions in the elderly
Psychological Interventions are effective in the elderly with behavioural and mental health disorders, and it appears the older adult population prefers psychotherapy to psychiatric medications (Areán, Alvidrez, Barrera, Robinson, & Hicks, 2002). However, in a survey of physicians, only 27% of respondents indicated they would refer depressed older patients to psychotherapy (Alvidrez & Areán, 2002). Tailoring psychotherapeutic intervention for older adults is often beneficial given comorbid medical complexities and the bidirectional relationship of mental health diagnoses with medical burden, disability, and cognitive impairment. In a review of psychotherapy in older adults, Raue and colleagues show there is evidence that cognitive behavioral therapy (CBT), problem‐solving therapy (PST), and interpersonal psychotherapy (IPT) are similarly effective for treating late‐life depression relative to depression in younger adults (Raue, McGovern, Kiosses, & Sirey, 2017). CBT has been utilized with demonstrated effectiveness in treating late‐life depression and anxiety as well as in those with comorbid depression and heart failure (Freedland, Carney, Rich, Steinmeyer, & Rubin, 2015) or Parkinson’s disease (Calleo, et al., 2015). Providing effective and appropriate psychological intervention can improve the primary psychiatric condition and may positively impact the severity of comorbid medical conditions and healthcare utilization. In a randomized controlled trial for the treatment of depression in heart failure, those receiving CBT versus treatment as usual demonstrated lower depression severity with higher depression remission rates and 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,
