7.8 Psychotherapy with older adults

Evidence

• Choose a psychological treatment by diagnosis, goals, preferences and communication needs, not by chronological age.

• The evidence is thinner for very frail people, unstable illness and substantial cognitive impairment, so adapt carefully and review the outcome.

• A 2009 meta-regression of 112 depression trials found similar effects in older adults (d = 0.74, 95% confidence interval 0.49 to 0.99) and younger adults (d = 0.67, 0.58 to 0.76), with no independent effect of age.

• The wider interval for older adults means less precision, not a weaker treatment.

The 1999 Pittsburgh trial studied maintenance treatment in adults over 59 who had recovered from recurrent depression.

• The combination did best, but this does not mean every older patient needs this drug or this schedule.

• Older people made only 5.6% of referrals to National Health Service (NHS) Talking Therapies in 2021/22, yet reliable recovery was about 61% at 65 to 74 against 51% at 26 to 64.

• Referral and outcome figures depend on definitions and selection, so they do not estimate the needs of all older adults.

• National Institute for Health and Care Excellence (NICE) guideline NG222 applies its psychological treatment options across adulthood.

• A difficulty with communication or with work between sessions calls for adaptation or a different approach, not automatic exclusion.

Adapting delivery

• Memory and processing difficulties are met with brief summaries, repetition, written or recorded material and reminders, and the therapist checks understanding rather than taking agreement as recall.

• Sessions go at the time of day when the person is most alert, with fewer new concepts, shorter appointments and breaks for pain, fatigue or breathlessness.

• Accessible print, good lighting, low background noise and hearing support improve sensory access.

• Video can help through facial cues or captions but is not always more accessible, so check equipment, data costs, dexterity and privacy rather than assuming digital ability from age.

• Home and care home visits improve access and allow practice where it matters, but practical help must not displace the agreed goals.

• Carer attendance is discussed separately, because the patient may disclose less with a relative present, especially when the relationship is part of the difficulty.

Themes

• Common themes are loss, illness, dependence, retirement, caregiving and a shorter future.

• Erikson's integrity versus despair and Butler's life review help explore meaning but do not replace an individual formulation.

• Panic in an older person may have lasted decades, and an understandable trigger does not make depression inevitable or untreatable.

• Baltes's selection, optimisation and compensation model guides adaptation: prioritise valued activities, strengthen remaining abilities and use support for what has become difficult.

• Therapists draw on previous coping without assuming that age brings resilience.

The therapeutic relationship

• Some patients take a protective or parental role towards a younger therapist, while others defer and conceal disagreement, so the therapist invites correction.

• Therapists may avoid ageing, death or dependence, or share the patient's hopelessness, and supervision should examine avoided topics and assumptions about change.

• Too much rescuing creates dependence, yet practical support may be what makes therapy possible, so plan the ending from the outset.

• A phrase such as "out of sorts" may describe severe distress, so ask for concrete examples rather than psychological vocabulary.

Choosing a model

• A 2010 trial found problem-solving therapy better than supportive therapy for depression with executive dysfunction, with the difference emerging after about six weeks.

• Reminiscence in dementia gives small benefits that vary with setting and format.

• NICE NG97 advises considering group reminiscence in mild to moderate dementia and offering group cognitive stimulation therapy, which is a distinct intervention.

Capacity, cognition and risk

• Dementia does not by itself remove capacity to consent to therapy.

• In England and Wales the person is supported to understand, retain, use or weigh and communicate the information, retaining it long enough to decide, not necessarily to recall every session.

• NICE recommends considering psychological treatment for mild to moderate depression or anxiety in mild to moderate dementia, and antidepressants are not offered routinely unless a pre-existing severe mental illness indicates them.

• Mild cognitive impairment or early dementia calls for repetition, memory aids and consented support for practice.

• With advanced impairment, consider behavioural, environmental and carer-focused work, but a stage label alone does not make individual work futile.

• Carer psychoeducation and skills training are recommended, and the START coping programme reduces carer anxiety and depression.

• Therapists monitor suicide risk throughout, plan a route back after illness, and adapt goals to function, such as attending part of an activity.

Cohort, culture and sexuality

• Some older people describe distress in physical terms or avoid psychiatric language, but beliefs are not inferred from age or culture alone.

• UK age of consent reform was enacted in 2000 and took effect in January 2001, and the World Health Organization removed homosexuality from its classification in 1990.

• These histories may shape trust, disclosure and bereavement, and a same-sex partner may be missing from records, so ask inclusively.

• Use professional interpreters, and consider migration, discrimination, income, heating, transport and digital access.

Measuring outcome and ending

• Track patient-defined goals and function alongside scores, since stability in progressive disease may be meaningful but does not prove a treatment effect.

• Discuss the ending early, and agree warning signs and an accessible relapse plan shared with carers or services as appropriate.

• After recurrent depression, review maintenance treatment individually.