How Cognitive Behavioural Therapy helps people with Alzheimer’s
About 90 % of all persons with mild Alzheimer’s disease experience neuropsychiatric symptoms, most frequently apathy, depression, anxiety and irritability. These symptoms are associated with greater morbidity, a reduced quality of life for the patient, an increased burden and depression for the caregiver, and higher costs of care and nursing home placement.
Alzheimer’s disease is a chronic debilitating mental condition manifested by cognitive and memory deterioration, progressive impairment in performing the activities of daily living and a variety of neuropsychiatric symptoms and behavioural disturbances. In 2006, the worldwide prevalence of Alzheimer’s disease was 26.6 million; this number is predicted to quadruple by 2050. Mild cases of Alzheimer’s disease make up the largest proportion of all Alzheimer’s disease cases, with 15 million worldwide.
Neuropsychiatric symptoms are a primary predictor of nursing home placement. Thus, interventions aimed at treating these symptoms might have a tremendous effect on patients, caregivers and society.
Teri et al. reported empirical evidence from a controlled clinical trial of two CBT-based interventions to treat depression in people with Alzheimer’s disease. One treatment involved increasing engagement in pleasant activities and events and the other involved behavioural problem-solving strategies. The participants in both intervention groups showed significant improvements in depressive symptoms compared with those in the two control groups, and these improvements were maintained for 6 months after the trial. The ‘pleasant events’ treatment resulted in a large effect size (d = 0.9–1.7 for three different depression measures), with 52 % clinically significant improvement (versus 20 % in the control groups). In addition, there were also significant improvements in caregivers’ depression scores, but no improvement for the caregivers in the control groups. Increasing engagement in pleasant activities, including social, physical and leisure activities, is not only important for reducing depression, but also decreases the amount of daytime sleep taken, improves night-time sleep and reduce wandering, aggression and agitation.
As well as behavioural techniques, cognitive restructuring is one of the major techniques in CBT. In their cognitive model of depression, Beck et al. describe cognitive schemas as core components of emotional disorders, e.g., a negative view of oneself, the world and the future (the ‘cognitive triad’) in the case of depression. Cognitive behavioural therapy includes strategies to change those negative thoughts and beliefs. Since the individual’s ability for introspection and reflection is a prerequisite of cognitive restructuring, and this ability is progressively impaired in dementia, it has been suggested that this technique is most likely to benefit patients with mild dementia. The point beyond which cognitive restructuring is not useful anymore has yet to be identified.
Structured life review
A structured life review was shown to be effective in treating depression in older people; in fact, it is among the most effective treatments for depression in older age. A structured life review involves individual sessions, in which a person is guided chronologically through life experiences and is encouraged to evaluate them. It is more effective than unstructured reminiscence therapy, one of the most popular psychosocial interventions in dementia (effect size: 0.92 versus 0.46, respectively). A life review is increasingly used for people with dementia and is effective in reducing their depression. Effect size is in average small for cognition (g = 0.33) and depression (g = 0.31). It helps patients with Alzheimer’s disease gain access to past memories and thereby enhances their sense of personal identity, maintains their self-worth and offers them a pleasurable experience.
The majority of the therapeutic techniques stem from the CBT literature, including behaviour analysis, psychoeducation, advice on establishing pleasant activities, guidance on self-reward to motivate oneself, cognitive restructuring through Socratic dialogue and guided discovery, training in behaviour management, problem solving and stress management. The life review, though not a CBT technique in origin, is used in a highly structured variant to fit into the general CBT approach. The techniques in the couples counselling sessions, which do not belong to traditional CBT either, mainly include adopted behavioural strategies, i.e., training in communication and problem solving, planning and cognitive restructuring.