Treating late-life anxiety in chronic medical illness and cognitive impairment: two case studies

Inger H. Nordhus and Minna J. Hynninen

in Casebook of clinical geropsychology

Published on behalf of Oxford University Press

Published in print September 2010 | ISBN: 9780199583553
Published online February 2013 | e-ISBN: 9780191754678 | DOI:
Treating late-life anxiety in chronic medical illness and cognitive impairment: two case studies

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In this chapter, we have outlined an individualized framework for the cognitive behavioral formulation of two older patients presenting with complex and co-morbid anxiety disorders. In presenting the two cases, we have emphasized the need to assess and interpret symptoms within a multifocus approach. Symptoms, as they appear in the clinical setting or are presented by significant others, involve a mixture of psychological as well as medical problems, which is an obvious premise in the case illustrations. If we add polypharmacy as another premise, we also need to be aware of the fluctuations in the symptom presentation. Understanding what the clinical presentation of co-morbid anxiety is, more often than not, a matter of team-work, and even more so in the older patient with medical and functional problems.

At the same time, when a case is defined as complex, involving cognitive and physical decline, we may be so eager to help that we lose the perspective of the person. We need to be aware of our own prejudices of older patients as fragile and helpless, and keep in mind that meeting an older person with multiple health problems represents a challenge that may be influenced by our a priori expectations of older people as fragile and helpless. Persons with cognitive impairment have regularly been excluded from clinical research as well as clinical practice. The case of Lise illustrates how in apparently difficult clinical presentations there is the potential to exploit the individual resources of the patient, still utilizing the well-known treatment options.

Throughout the chapter, we have sought to emphasize the importance of using established and well-known treatment models with older adults. At the same time, we have illustrated the importance of using treatment options flexibly and adapting them to the individual patient and his or her problems. The phenomenon of safety behavior, that is, the overt or covert avoidance of feared outcomes that is carried out in a specific situation (Salkovskis, 1991), may illustrate this point. It is widely asserted by clinicians as well as researchers, that safety behavior is countertherapeutic and should be extinguished. Safety behavior generally is conceived of as providing only temporary relief from symptoms, and may eventually be a cause of persisting anxiety. In a patient with COPD and anxiety, such as John, it was not easy to establish whether his overt safety behaviors were appropriate or not, given his respiratory illness. In recent literature, it has been emphasized that anxiety-control strategies such as distraction (e.g. attention management) may not necessarily be conceived of as counterproductive in treating anxiety (Parrish, Radomsky, & Dugas, 2008). Although a thorough discussion of the relevance of various therapeutic mechanisms is beyond the scope of our chapter, it is interesting to note that carrying out psychological treatment in older patients with complex symptomatology may result in more focused attention on what mechanisms lead to a positive treatment outcome and what mechanisms are less productive.

One further aspect deserves mentioning. We know too well that not having access to psychological treatment is a common issue in most countries. Whether we live in Europe, Australia, or the United States, older people have not been a major concern in mental health services. There is reason to believe that psychological treatment for older adults is a slowly growing enterprise. Taking mental health problems into contexts like primary care and medical settings should be added to our agenda.|

Chapter.  9608 words. 

Subjects: Psychiatry ; Geriatric Medicine

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