Cognitive Behavioural Therapy (CBT) for

anxiety in dementia: A qualitative study exploring the CBT experience of dementia

patients and their carers

Mary Opoku (2012)

Dementia is neuro-degenerative disease common in older people

700,000 people in the UK have dementia Dementia causes decline in cognitive

functioning (e.g. memory and language) and behavioural problems.

Lead to reduction in quality of life, relationship difficulties, physical dependencies and risk of admission to nursing homes.

Background – Dementia

Two-thirds of people with dementia suffer with anxiety (Dementia UK, 2007)

Antipsychotic medication pre-dominantly used to treat dementia, which are limited in it’s overall effectiveness (NICE, 2007)

Some of the side effects of these medication include:

Depression Stroke Further decline in thinking Additionally older people generally prefer therapy

to medication

Background – Anxiety in dementia

Despite this limited evidence base, latest dementia guidelines (NICE, 2007) recommends CBT as a non-medical treatment for anxiety

Cognitive Behavioural Therapy (CBT) is a person-centred, talking therapy that addresses the thought and feelings associated with anxiety (developed by Beck et al, 1979).

It teaches people new skill to manage their anxiety.

Cognitive Behavioural Therapy (CBT)

Treatment of choice for other population, including older people in general (NICE 2007).

Widely adopted by the NHS and initiatives such as ‘Improving Access to Psychological Therapy (IAPT, DoH 2008) for people of ‘working age’ have been set up to support the implementation of CBT for depression and anxiety within local primary teams

There is evidence form research with individual cases that CBT has a great potential to help reduce anxiety and improve mood in people with dementia.

CBT as a treatment

Three case studies examining CBT for anxiety in dementia (Kraus et al, 2008) found:Changes in thoughts, feeling and

behavioursClinical reduction in anxiety Improved moodParticipation in pleasurable activities Reduced insomnia

CBT as a treatment

Aim : To develop a randomised controlled trial (RCT)

as well as national manual in using CBT treatment nationwide in dementia services

To test whether CBT reduces anxiety in people with dementia and additionally improves their cognitive problems, everyday behaviour and quality of life.

Also test also test if it improves relationship for carers, as they develop new skills to help support their relatives

The Main Trial

10-weekly CBT treatment with a Qualified Clinical Psychologist:

•Identifying and noticing unhelpful thoughts •Behaviour experiments•Thought diaries•Anxiety ratings•Progressive muscle relaxation training•Homework

The Main Trial

Rationale for qualitative research:To use qualitative methods to gain deeper

understanding of how person with dementia and their carers experienced the CBT intervention.

To explore process and outcome of the treatment from the participant’s perspective

To use finding to develop as well as guide and inform future application of the intervention

This Project

The exploratory research questions aim: To explore the potential benefits and

challenges of the CBT processes from participants perspective

To explore outcome of the intervention as perceived by participants

To find out whether CBT has continual benefits

To explore themes emerging from analysis around the intervention process and outcome

This Project:

Sample: Recruited from North East London NHS Trust

via memory service, community mental health teams and GPs

All had taken part in the ten-weekly CBT sessions

All participants were met in their homes after agreeing to take part

Method

Participants: Caucasian/ white British6 people with dementia (3 males and 3

females) and their carers (6 carers) Older Adults 63 and 88 years All participants presented with mild levels of

cognitive impairment on the Mini Mental State Examination (MMSE)

Method

All measures used to explore participants’ experience of the CBT intervention were presented through a one-to-one face-to-face semi-structured conversational interview style. The qualitative interview questions were an adaption and extension of the five broad themes used by Finucane and Mercer (2006), which was appropriately modified for the current study. The five broad themes were: 1) The intervention techniques, methods and materials 2) The format of the intervention 3) Changes and current coping skill 4) Continuous practice of CBT techniques. 5) Participants overall impression

The Qualitative Interview

The interviews will be transcribed word for word

The transcriptions were compared with the audio interviews to ensure accuracy.

A Framework analysis (Ritchie and Spencer, 1994) will used used to extract themes and to draw conclusions. Used because it facilitates systematic analysis of a large amount of data.

Analysis

Subsequently, preliminary themes/concepts will be generated and coded using Atlas qualitative research software. Thematic charts will be produced for each

theme with supporting document. Person with dementia and carer are analysed

separately initially, however many overlapping themes emerged and the final coding integrated both perspective, encompassing both similarities and differences

Analysis

There will be a co-coder with whom codes will be compared with and themes will be reviewed in order: to come to a consensus and for inter-rated reliability. Used in order to for methodological robustness for good practice in qualitative research

Data still at the analysis stages…

Analysis

The analysis generated 17 central themes, each with several sub-themes grouped into three broad domains, which were engagement in CBT, process of change and outcome in key areas of functioning.

Participants were largely positive about how they perceived the therapeutic relationship and ability apply CBT techniques such as relaxation

Preliminary results

This research adds to the evidence base for CBT and demonstrates that an inductive approach, eliciting the views of the person with dementia themselves and their carer, can contribute to investigation of treatment processes and outcomes.

Implication

Kraus, C., Seignournel P., Balasubramanyam, V., Snow, L., Wilson, N.L.,Kunik, M.E., Schulz, M.D., Stanley, M.A., 2008. Cognitive behavioural treatment for anxiety in two patients with dementia: two case studies. Journal of Psychiatric Practice 14 (3), 186–192.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York

References