Clinical Geriatrics

Case Presentation

A 71-year-old married man was seen regularly by his geriatric physician for hypertension, irritable bowel syndrome, depression, and anxiety. He requested frequent medical appointments and always came prepared with a list of questions about his health. His anxiety increased when he read about his conditions and medications in medical guides and on the Internet. He had been given several trials of antidepressants, but perceived intolerable side effects from each. His physician referred him to a cognitive behavioral therapy (CBT) group for treatment of depression and anxiety.

The patient was retired from his career as a pharmacist at a local drugstore. He had enjoyed the status and challenge of his job and, after retirement, believed that he no longer had a purpose in life. Depressive symptoms had been present during his working years, but his anxiety had developed after retirement. He became disinterested in previously enjoyable activities and withdrew from social contact, such as membership in a service organization. He became disorganized and lost confidence in his abilities. He had trouble making decisions and was continually looking for reassurance that he would be alright.

In an initial interview with one of the group facilitators, the patient described his physical illnesses at great length. He brought with him a carefully packed kit including several medications, instructions for taking them, a selection of snacks, and an outer garment in case of a change in weather. He described how he always double-checked this kit each time he left his home. His score on the Geriatric Depression Scale was 15 out of 15, and his score on the Burn’s Anxiety Inventory1 was 50, indicating severe anxiety.

Discussion

Mood disorders, especially depression and anxiety, are common conditions among older adults. Although mood disorders can be related to physical as well as psychological factors, distorted thoughts or beliefs often serve to create or maintain dysfunctional mood states. At the same time, when feeling depressed or anxious, individuals tend to find evidence that supports distorted or negative thoughts.

Cognitive therapy was developed in the late 1950s by Aaron Beck to help individuals overcome depression. Current research shows a growing body of evidence attesting to the benefits of CBT, whether alone or in combination with appropriate psychotropic medication, for treatment of late-life depression and anxiety.2-5 The cognitive model proposes that distorted or dysfunctional thinking influences mood and behavior, and that realistic evaluation and modification of thinking produce an improvement in mood.6 Using cognitive therapy does not imply replacing inaccurate negative thoughts with inaccurate positive thoughts, but rather describing a situation or event in accurate, realistic words.

Outpatient CBT groups offer cost-effective, clinically efficient help for mood disorders.7,8 The group discussed in this article was offered to those over the age of 60. Seven participants attended 10 weekly sessions of 11/2 hours each facilitated by two clinical social workers. Concepts of cognitive therapy were introduced in an educational mode, using tools such as lectures and reading assignments. Members were given homework assignments to enhance their understanding of the therapy and to work toward identified goals. Weekly sessions followed a similar format and included these components:

Go-around question. Each session began with a brief go-around question such as, “What was a core value of your family of origin?” Discussion following this question emphasized how family values learned in formative years can affect thoughts, attitudes, and behaviors throughout life. When discussing core values, the patient described in this case became more aware that his perfectionism was related to his father’s high standards and refusal to accept mistakes.