Handbook of Psychosocial Interventions with Older Adults

Evidence-based approaches

Sherry M. Cummings, Nancy P. Kropf

• Publisher: Taylor & Francis
• Year: 2013
• eBook ISBN: 9781317990291
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

In the past decade, evidence based practice (EBP) has emerged as one of the most important movements to improve the effectiveness of clinical care. As the number of older adults continues to grow, it is essential that practitioners have knowledge of effective strategies to improve both the medical and the psychosocial aspects of older persons' lives. The purpose of this work is to present systematic reviews of research-based psychosocial interventions for older adults and their caregivers.

The interventions presented focus on a variety of critical issues facing older adults today including medical illnesses (cardiac disease, diabetes, arthritis/pain, cancer, and HIV/AIDS), mental health/cognitive disorders (depression/anxiety, dementia, substance abuse), and social functioning (developmental disabilities, end-of-life, dementia caregivers, grandparent caregivers). For each of these areas the prevalence of the problem, the demographics of those affected, and the nature and consequences of the problem are discussed. The empirical literature is then reviewed. A treatment summary highlights the type and nature of research supporting the interventions reviewed and is followed by a conclusion section that summarizes the status of intervention research for the specified issue. A Treatment Resource Appendix for each area is included. These appendices highlight manuals, books, articles and web resources that detail the treatment approaches and methodologies discussed.

This book was previously published as a special issue of the Journal of Gerontological Social Work.

Chapter 1
Overview of Evidence-Based Practice with Older Adults and Their Families

Sherry M. Cummings, PhD
Nancy P. Kropf, PhD

Currently, there are about 37 million persons 65 years of age and over in the United States. By the year 2030, the number of older adults will more than double to about 80 million, with the greatest increase occurring among those aged 85 years and older (Census Bureau, 2004). Later life often ushers in a variety of challenges for older individuals such as acute medical illnesses, chronic conditions, functional impairment, loss of family and friends, and cognitive changes. These challenges represent risks to older adults for decreased quality of life and for increased morbidity and mortality.

In the past decade, there has been a tremendous growth in research for interventions for older adults. Unfortunately, however, interventions supported by research are not routinely offered in many practice settings. Although older adults are responsive to mental health treatment, for example, those with mental health disorders are more likely to receive inadequate or no treatment as compared to younger adults (Bartles, Dums, Oxamn, Schneider, Arean, Alexopoulos, & Jeste, 2002). In addition, while many conditions experienced by older adults are treated medically, the emotional, psychological, and social aspects of their illnesses or conditions often remain unaddressed. The neglect of such critical dimensions of an older client’s life may result in non-compliance with medical regimens, increased stress, delayed recovery from medical conditions, and increased impairment. As the number of older adults continues to grow, it is essential that practitioners have knowledge of effective strategies to improve both the medical and the psychosocial aspects of older persons’ lives.

Over the past decade, there has been tremendous growth in the movement to enhance the delivery of quality services through the use of evidence-based interventions. It is now widely agreed that in order to ensure the delivery of the best services to meet clients’ needs, practitioners’ decisions must go beyond clinical judgment and expertise to include knowledge of evidence-based practices (Gambril, 1999, 2001; Gilgun, 2005). The adoption of interventions whose effectiveness have been demonstrated by clinical and social services research can serve to enhance the quality of service delivery and, thereby, improve the lives of many individuals.

For this reason, in the last decade evidence-based practice (EBP) has emerged as one of the most important movements to improve the effectiveness of clinical care. EBP can be understood as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individuals (Sackett, Richardson, Rosenberg, & Haynes, 1997). Begun in the field of medicine in the early 1990s, the emphasis on EBP has now spread to a variety of fields including nursing (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996), psychology (Gatz, Fiske, Fox, Kaskie, Kasl-Godley, McCallum, & Wetherhall, 1998), psychiatry (Bartles et al., 2002), and social work (Gambrill, 2001, 1999, 2005; Gilgun, 2005).

Although there is a body of evidence supporting the effectiveness of certain interventions for older adults, a substantial gap remains between this growing body of knowledge and treatments routinely used in practice settings (Torrey, Drake, Dixon, Burns, Flynn, Rush, Clark, & Klatzker, 2001). Recognizing that access to relevant research findings is critical to fostering awareness and usage of evidence-based interventions, there have been increased calls for greater availability of rigorous research reviews in recent years (Gambril, 1999; Gilgun, 2005). While a growing number of reviews have examined the effectiveness of pharmacological interventions for older adults, few have examined that status of psychosocial interventions for the older population. The purpose of this current work is to address this gap by presenting systematic reviews of research-based psychosocial interventions for older adults and their caregivers.

The interventions presented within the following articles focus on a variety of critical issues facing older adults today including medical illnesses (cardiac disease, diabetes, arthritis/pain, cancer, and HIV/AIDS), mental health/cognitive disorders (depression/anxiety, dementia, substance abuse), and social roles (developmental disabilities, end-of-life, dementia caregivers, grandparent caregivers). Each article discusses the prevalence of the problem, the demographics of those affected, and the nature and consequences of the problem. The empirical literature is then reviewed using specific parameters. The following criteria for evidence-based treatment were utilized:

Level 1–evidence is obtained from a meta-analysis of all relevant randomized controlled studies (RCS) or from a systematic review of RCS
Level 2–evidence is obtained from at least one properly designed RCS
Level 3–evidence is obtained from well-designed controlled studies without randomization
Level 4a–evidence is obtained from non-controlled studies
Level 4b–evidence consists of consensus reviews that represent the opinions of respected authorities based on clinical experience or reports of expert committees.

Studies of individual, family, and group interventions as well as community and institution-based interventions were considered for each review. Only those research studies whose participants consisted of older adults were included; however, no one established definition of older adult was provided. Rather, older adult is defined within the context of each specified illness/condition. For each review, information concerning the databases searched, search terms used, and time period considered is clearly provided. A treatment summary highlights the nature and type of evidence-based interventions reviewed and is followed by a conclusion section that summarizes the status of intervention research for the specified issue, identifies gaps in knowledge, and suggests directions for future research. Each article concludes with a Treatment Resource Appendix that highlights manuals, books, articles and web resources that describe treatment approaches and methodologies.

Organization of Volume

Health Conditions

The article by Peck and Ai addresses the status of psychosocial interventions designed to enhance the well-being of older adults with cardiovascular disease (CVD), the leading cause of death in the US. The impact of psychosocial issues on CVD morbidity and mortality is well-documented. Co-morbid mental health disorders, for instance, are common in CVD patients and are linked with CVD mortality and poor quality of life. Poor social support has also been identified as a predictor of CVD mortality while stress is a major risk factor for the development of CVD. Over the past 20 years psychosocial interventions for persons with CVD have been offered to improve the psychological and physical well-being of CVD patients through the modification of thoughts, behaviors and mood. Common intervention approaches to accomplish this goal include health education, stress management, relaxation therapy, cognitive behavioral therapy (CBT), and group support. The review of two decades of research affirms the efficacy of psychosocial interventions to enhance the mental health and quality of life of older persons with CVD. This same research, however, calls into question the utility of such interventions as methods for reducing mortality in this population.

Maramaldi, Dungan, and Poorvu discuss issues confronting older individuals diagnosed with cancer and the status of interventions that seek to improve their psychosocial and physical functioning. A wide variety of psychosocial treatments for older persons with cancer have been developed and tested. The majority of these utilized group formats and incorporate education, support, psychotherapy, and/or relaxation techniques in order to improve mood, increase knowledge, enhance coping, and decrease stress. Some interventions have also targeted spouses of cancer patients and employed group formats to enhance spousal coping and marital satisfaction. Although the emotional, psychological and social impact of living with cancer is well-recognized and a variety of psychosocial treatments have been tested, information concerning empirically validated psychosocial interventions with cancer patients is limited when compared with the extensive medical intervention literature in this field.

The article by Yoon and Doherty focuses on psychosocial interventions for one of the most prevalent chronic health problems and the leading cause of disability among older Americans, arthritis and arthritic pain. Because the importance of psychological and social factors in the management of chronic pain is well-recognized, a range of psychosocial treatments exists. Among these, cognitive behavioral therapy and psychoeducational interventions have received the greatest empirical support. Meta-analyses and randomized controlled studies have documented the benefits of interventions incorporating these approaches. Some of the interventions utilizing these techniques have also been replicated with Spanish-speaking elders and with older adults living in foreign countries. However, the authors note that since many of the psychosocial treatments studied were multi-modal and integrated a variety of psychosocial approaches, it is difficult to determine which particular components or combinations of components have the greatest treatment efficacy.

In the fifth chapter, Vaughn DeCoster discusses diabetes, a leading cause of disability and death in older adults. Close to 20% of persons 60 years of age and older have diabetes while another 20% are at heightened risk of developing this disease. Proper diabetes management involves significant life-style changes including adherence to a medication regime, dietary control, and exercise. Non-compliance with the prescribed routine of care can result in blindness, amputations, kidney disease and death. In response, psychosocial interventions have been developed to increase compliance with care regimens through modification of health and life-style behaviors, and to improve quality of life through enhanced psychological and social well-being. Currently, much of the psychosocial intervention research in this area concentrates on exploratory research and pilot testing of intervention protocols. Psychosocial interventions in this area utilize a variety of group and individual approaches that incorporate social support, education, problem-solving, case management, exercise, and computer assisted diabetes care. The studies reviewed suggest that such interventions are efficacious in helping older persons with diabetes to increase their knowledge and self-care behaviors, and to improve their diet, quality of life and blood sugar levels.

Emlet and Shippy provide an overview of the unique challenges faced by older persons living with HIV/AIDS in chapter six. These challenges represent the convergence of physical, psychosocial, spiritual and service issues faced by a hidden group of older adults. Although AIDS cases among Americans over 50 have quintupled since 1990 and older adults now represent approximately 20% of all persons living with HIV, little attention has focused on the needs of this population. The number of older adults with HIV/AIDS, however, is expected to grow rapidly due to highly effective therapies that allow many people to live for significantly longer periods of time, and to ineffective HIV/AIDS prevention efforts targeting older adults. Research on psychosocial interventions for persons with HIV/AIDS is in the nascent stage and even within this arena studies focused on older adults are rare. However, within the past five years a few such studies have taken place. These studies represent emerging efforts to conceptualize and test psychosocial HIV/AIDS interventions and, through such efforts, lay the beginning groundwork for future development and exploration of treatments to promote the functioning and well-being of older adults living with HIV/AIDS.

Cognitive and Mental Health Issues

Turning to later-life mental health/cognitive disorders, Adamek and Slater, in chapter seven, review the multiple studies and meta-analyses that have examined the efficacy of psychosocial interventions to treat depression and anxiety in older adults. These studies provide strong evidence that a range of psychosocial interventions, such as CBT, Reminiscence Therapy, and Problem-Solving Therapy, provide significant benefit over and above placebos for improving the mental health status of depressed older adults. Although not as many studies have been conducted on psychosocial treatments for late life anxiety as have been for depression, a substantial number of studies do exist that support the usefulness of CBT, offered in either individual or group format, for reducing anxiety among older adults.

Due to the devastating and costly nature of Alzheimer’s Disease for older adults, their families, and society as a whole, much research has been focused on determining strategies to slow or stop the progression of this disease. However, much less attention has been paid to developing and testing psychosocial treatments to reduce problematic behaviors and negative mood states among those afflicted. Sanders and Morano examine the small but varied body of research in this area. They report that while interventions for individuals with dementia have had mixed results, evidence does suggest that psychosocial treatments can reduce depression, anxiety, and agitation and improve social interactions, awareness, and recognition among those with dementia.

Cummings, Bride, Cassie, and Rawlins-Shaw discuss the nature of and treatment for substance abuse among older adults in chapter nine. Research in this area is complicated by definitional ambiguity. No agreement exists as to what constitutes an older person in addictions research and persons defined as older in the studies examined ranged in age from 45 years and over to 60 and above. Likewise, definitions of conditions such as alcohol abuse also vary significantly. However, the available research does reveal positive outcomes for older substance abusers including abstinence, reduction in use, and improved general health. The research also suggests that older substance abusers achieve the best results when a cognitive-behavioral approach is utilized, and have better treatment compliance and outcome when treated in an older adult specific program.

Social Functioning

Articles nine through twelve turn our attention to interventions designed to promote social role functioning among older adults and their caregivers. In chapter ten, McCallion and Nickle review psychosocial treatment studies focused on older adults with developmental disabilities (DD) and their family members. Research in this area is in the beginning stages and, thus far, has focused on promoting life skills among older adults with DD and on strategies to enhance caregivers’ future planning ability. These studies suggest that futures planning interventions can enhance caregivers’ knowledge and awareness of planning resources and their competence, confidence, and progress in future planning for their aging son or daughter. In addition, research on social role functioning of adults with DD themselves is included in this article. Examples of particular issues and conditions include dealing with residential concerns and leisure-based options, and assisting the person with DD deal with grief and loss situations. While many studies in this area suffer from small sample size and lack of control/comparison groups, they do lay the groundwork for future research on interventions to promote the quality of life and care for this growing and vulnerable population of older adults.

Scientific and medical advances have changed the nature of dying in the US and have highlighted the need for comprehensive approaches to end-of-life care. In chapter eleven, Deborah Waldrop underscores the essential interrelationship between the patient experience, caregiver experience, and advanced care planning in end-of-life treatment. While a myriad of intervention studies exist that examine the medical aspects of end-of-life care, those exploring the psychosocial aspects are less common. Thus far, the psychosocial intervention studies that have been conducted, focus on enhancing end-of-life care for terminally ill older adults and on promoting healthy grief experiences for surviving care-givers. In particular, these studies examine the impact of psychosocial treatments on dying individuals’quality of life, end-of-life preferences, satisfaction, and emotional and cognitive functioning, while bereavement studies target family members’ grief, coping, and mood. Results of research studies in this emerging field affirm the promise of psychosocial treatments to promote enhanced care at end-of-life, and highlight the need for further development in the area of bereavement intervention.

In chapter twelve, Cassie and Sanders explore the results of psychosocial interventions designed to enhance the functioning of family members providing care to older relatives in the well-developed field of caregiver research. Results of meta-analyses and research studies on individual and group caregiver interventions, as well as multi-modal and technology-based interventions for caregivers are reviewed. Results of these studies provide strong evidence supporting the utility of psychosocial interventions for reducing negative mental and physical consequences of providing care and for enhancing caregivers’ coping and...

Table of contents

• Cover
• Title
• Copyright
• CONTENTS
• Preface
• Chapter 1. Overview of Evidence-Based Practice with Older Adults and Their Families
• EVIDENCE-BASED INTERVENTIONS FOR HEALTH CONDITIONS
• EVIDENCE-BASED INTERVENTIONS FOR COGNITIVE AND MENTAL HEALTH ISSUES
• EVIDENCE-BASED INTERVENTIONS FOR SOCIAL FUNCTIONING
• Index