Effectively using cognitive behavioral therapy with the oldest-old: case examples and issues for consideration

Dolores Gallagher-Thompson and Larry W. Thompson

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:
Effectively using cognitive behavioral therapy with the oldest-old: case examples and issues for consideration

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Although it is very true that CBT can be effective to treat moderate levels of depression in very old adult outpatients, as evidenced by the case examples presented here, CBT may require more sessions than is typical, and more creative problem solving on the therapist's part, to engage and retain these very old patients in treatment. Practical problems such as transportation and scheduling need to be dealt with on an individual basis, and the health status of the patient must be inquired about and adjusted for—particularly for those patients with significant medical co-morbidities. In addition, the role of the family (along with any part they will play in the therapy) needs to be assessed at the outset and re-assessed as therapy progresses. As well, the presence of mild-to-moderate cognitive impairment signals that therapy will take longer, move more slowly, and have many challenges along the way.

Taken together, these observations suggest that CBT should be used cautiously with patients over 80 who have significant health issues and/or mild-to-moderate cognitive impairment concomitant with their depression. We recommend that CBT be initiated on a trial basis and that four to six sessions be held to evaluate the extent to which it is likely to be responded to effectively by each particular patient with these characteristics.

In about one-third of patients referred to the authors for therapy, only one or two sessions took place, and then the patients discontinued on their own. Follow-up phone calls with patients who discontinued indicated reasons such as: they did not feel comfortable with the explanation provided of what CBT involved, or they did not feel they could make the commitment to come in for regular sessions over a sustained period of time, or they really felt they needed a different kind of help.

Others wanted only a “supportive listener” and not a true therapist. For example, both authors have had experience with patients who just want someone to talk to, and who do not want to do the work of CBT. This becomes apparent when trying to delineate goals, or when discussing the expectation that home practice will be done between sessions to foster learning and therapy gains. When patients say they don't have any goals except to “feel better” and despite one's best efforts, no specific goals can be set, or when patients say they simply will not be able to do any home practice assignments between sessions, these are therapeutic “red flags” that CBT is not likely to be successful and perhaps an alternative therapy should be considered. Those who are medically unstable are not likely to be able to fully participate in CBT (even if they want to) due to unexpected health declines, medication reactions, required tests, and frequent medical appointments. This is more likely to happen with increasing age, so unless the therapist can be extremely flexible with the timing (and location) of appointments, these are patients who perhaps should be referred for another form of therapy. On the other hand, a CBT approach with more limited goals may be appropriate and helpful to such patients—although full remission from the depressive episode may not be achieved due to the intermittent nature of the therapy contacts. Finally, in our experience, patients with extensive social work needs (housing options; how to get a financial benefit they feel they are entitled to, etc.) are usually not able to engage in CBT until these needs have been met. For those individuals, completing work with the social worker first may be necessary before CBT commences.

Chapter.  10008 words. 

Subjects: Psychiatry ; Geriatric Medicine

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