Many patients with cognitive impairment have anxiety or depression, but standard treatments are difficult for people with memory issues.
By Dec. 8, 2019)
Anne Firmender, 74, was working with her psychologist to come up with a list of her positive attributes.
“I cook for others,” said Ms. Firmender.
“It’s giving,” encouraged the psychologist, Dimitris Kiosses.
“Good kids,” continued Ms. Firmender, who has four grown children and four grandchildren.
“And great mother,” added Dr. Kiosses. Ms. Firmender smiled.
Dr. Kiosses typed up the list and handed a printout to Ms. Firmender to take home. “When you’re feeling down and hard on yourself, you can remind yourself of your strengths,” he told her.
Ms. Firmender, who has a history of mental health problems, was in therapy for depression. But she also has mild cognitive impairment and can have trouble remembering what day it is. So Dr. Kiosses was treating her with a novel approach called Problem Adaptation Therapy, or PATH. The therapy, developed at Weill Cornell Medicine in New York City and White Plains, N.Y., focuses on solving tangible problems that fuel feelings of sadness and hopelessness. It incorporates tools, like checklists, calendars, signs and videos, to make it accessible for people with memory issues. A caregiver is often involved.
The approach is one of several new psychotherapies to treat anxiety and depression in people with cognitive impairments, including early to moderate dementia. Another, the Peaceful Mind program, developed by researchers at Baylor College of Medicine and elsewhere for patients with anxiety and dementia, simplifies traditional cognitive behavioral therapy and focuses on scheduling pleasurable activities and skills, like deep breathing. Therapy sessions are short and take place in patients’ homes. A program designed by researchers at University College London gives cards to patients to take home to remind them of key strategies. One that says “Stop and Think” prompts them to pause when they have panicky and unhelpful thoughts to help keep those thoughts from spiraling and creating more anxiety.
Early research on the new approaches is encouraging, but longer and larger studies will be needed to fully assess the effectiveness. In a study published in JAMA Psychiatry involving 74 people with major depression and mild cognitive impairment or mild to moderate dementia, patients who had 12 sessions of PATH had a 43 percent greater reduction in their scores on a measure of depression symptoms compared with those in the control group who received 12 sessions of “supportive” therapy. (In the control treatment, therapists focused on conveying empathy and helping patients express their emotions.) At the end of treatment, 38 percent of patients who had PATH were in remission from their depression, compared with about 14 percent in the control group. In this study, both treatments were given at home.
A small pilot study of the Peaceful Mind program, published in the American Journal of Geriatric Psychiatry, found that clinicians rated patients who had received three months of weekly sessions as less anxious, compared with a control group. Peaceful Mind participants also rated themselves as having a higher quality of life. But the differences were not evident at six months.
Brent P. Forester, chief of the division of geriatric psychiatry at McLean Hospital in Massachusetts who was not involved in the research on the programs, said the approaches were promising and could fulfill a crucial need since current treatments for depression generally don’t work well in people with cognitive impairments.
“Finding new interventions could be extraordinarily helpful in terms of quality of life,” he said.
Depression and anxiety are very common among people with mild cognitive impairment and dementia. Research shows that about a third of people with dementia also have depression, and that anxiety symptoms afflict roughly a quarter to half of patients with Alzheimer’s disease and other forms of dementia.
At the same time, a history of major depression increases the risk of developing Alzheimer’s later in life. Scientists aren’t sure exactly why that is, but one theory is that high levels of the stress hormone cortisol, which can occur with depression, is toxic to the hippocampus, a part of the brain that is critical for storing long-term memories.
Especially in dementia’s early stages, people may feel a lack of motivation, apathy, social isolation and fear, Dr. Forester said. “People are very often aware of losing their memory and they are very scared,” he said.
Depression and anxiety can make dementia symptoms worse. “People with a diagnosis of dementia can become very anxious about getting things wrong. They might struggle to find what they want at the store and worry about how to pay for things,” said Aimee Spector, a professor of old age clinical psychology at University College London, and a creator of their cognitive behavioral therapy program for people with anxiety and dementia.
These fears can lead patients to curtail normal activities, causing more cognitive problems. “We know the brain needs to stay active and people need to remain cognitively challenged. There can be a negative spiral in dementia symptoms,” Professor Spector said.
Indeed, people with dementia who also have depression are more functionally impaired and are more likely to be placed in a nursing home, according to a study published in 2005 in the American Journal of Geriatric Psychiatry. Still, depression is woefully undiagnosed and undertreated in dementia patients. The same study found that only 35 percent of dementia patients with depression were accurately diagnosed and adequately treated for their depression.
While the science is mixed, research has generally found that antidepressant drugs don’t work well in older adults with cognitive impairments. Still, many people with anxiety and depression and dementia are prescribed psychiatric drugs.
“The medications are given out almost automatically,” said Lon Schneider, professor of psychiatry, neurology and gerontology at the University of Southern California.
Many psychiatric drugs come with serious risks and side effects for older people. SSRI antidepressants like Zoloft and Prozac are associated with fractures and falls in seniors. Antipsychotic medications like haloperidol and risperidone, which are often given for anxiety and agitation, can increase the risk of death in people with dementia. Benzodiazepines like Klonopin and Xanax, often used for anxiety, can cause falls and confusion.
Effective psychotherapy could be a safer alternative. The goal of PATH is to “reduce negative emotions the patient has and increase positive emotions,” said Dr. Kiosses, who is also an associate professor of psychology in clinical psychiatry at Weill Cornell Medical College. Patients are taught to identify the situations that trigger negative emotions like sadness, anxiety, guilt, helplessness and hopelessness. They are also taught to shift their attention away from those situations and emotions. That is part of the thinking behind the list of positive attributes that Dr. Kiosses worked up with Ms. Firmender.
PATH is based on problem-solving therapy, a treatment that focuses on helping people solve everyday problems that are causing distress. At the end of each session, therapists give patients a written summary to help them remember skills.
They may also send patients home with tools to jog their memory. For an 84-year-old patient who struggled with feelings of loneliness, the therapist and patient put signs in the patient’s living room that said, “Going to church will make me feel better” and “Staying home makes me sad.”
A caregiver is often enlisted to help patients use the skills they’ve learned.
Micky, 75, had no history of depression before he was hit by a car while riding his bicycle in 2013, resulting in a head injury that left him with short-term memory problems. He forgets conversations and sometimes gets lost while driving. In the years after the accident, he became lethargic and deeply missed cycling, said his wife, Lorry. The couple asked to be identified by only their first names for privacy reasons.
Micky did the PATH program at Weill Cornell, before moving recently to North Carolina. His wife accompanied him to every session.
To address his difficulty falling asleep, his therapist suggested that “he think good thoughts before you go to sleep,” Lorry said. So, as the couple got ready for bed each night, she would remind her husband of that suggestion.
“He said, ‘I’m doing it. I’m doing it,’” Lorry said. “Thinking about our granddaughter, he said it was helpful.”
In her therapy session with Dr. Kiosses, Ms. Firmender, a black cane resting against her chair, answered a question the therapist asks her every week: What pleasurable activities had she done in the past week and what were her plans for the upcoming week?
Scheduling pleasurable activities — what is known as behavioral activation — is a technique that has been found to boost mood. Ms. Firmender told him she volunteered at the thrift shop at church.
“I always enjoy that,” she said. The upcoming week she was planning to make corned beef and cabbage for her fellow volunteers.
Laura Gitlin, dean of the College of Nursing and Health Professions at Drexel University, said that adding meaningful activities to the day is particularly crucial for people with dementia, who often face blank calendars as their cognitive problems grow.
“Boredom and having nothing to do contributes to having an array of behavioral symptoms, agitation, aggressiveness, apathy, rejection of care,” she said. Dr. Gitlin and colleagues have developed the Tailored Activity Program that identifies activities that are meaningful to people with dementia — it could be woodworking or making a salad — adapts them to their abilities and regularly schedules them into the patients’ days.
“Activity is part of what makes us human,” Dr. Gitlin said.
Patients being treated with PATH include those who are having their first episode of depression, and those, like Ms. Firmender, who have long struggled with mental health issues. She has seen a therapist for 20 years and has been on various psychiatric medications.
Over the years, the depressive thoughts have waxed and waned. About three years ago, Ms. Firmender was hospitalized for suicidal thoughts and underwent a course of electroconvulsive therapy. After another brief hospitalization, she did PATH in early 2018 as a participant in a Weill Cornell study looking at the treatment for suicidal ideation. After her depression symptoms surged again recently, Dr. Kiosses started her on another course of PATH, this one focused on depression.
When Ms. Firmender slides into depression, she turns to writing poetry. During one therapy session, she took out a yellow notebook and read a verse she wrote:
I can’t find my happy place
It was never easy to find but now it seems forever gone
It’s in my mind in some deep dark places.
Ms. Firmender said the program was helping her get a handle on such feelings. What she really likes is that it focuses on solving problems.
“It isn’t, ‘oh, poor Anne,’ because then you do nothing about it and you feel worse, you feel really sorry for yourself,” she said. “It’s like, ‘O.K., Anne, what are you going to do about it?’”