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Delivering effective psychological therapies and interventions to older people

The BABCP and Age UK updated their ‘Talking Therapy Positive Practice Guide’ in 2024(1) and, although written in the NHS England service context, this provides an excellent guide to delivering psychological interventions to older people and is core reading for those new to providing services to older people or needing to refresh their knowledge. Here we summarise key themes from this document and other resources.

Do Older People benefit from psychological interventions and therapy?

There is good evidence from a range of sources that psychological therapy is effective with older people and psychological therapists can be confident that older people who are offered psychological interventions and therapy are likely to benefit from treatment. NICE (2020, 2022)(2,3) guidance does not require specific adjustments to standard treatments for older adults with anxiety or depression, indeed practice-based evidence suggests that older people may have better outcomes in treatment than younger adults (Saunders et al., 2021)(4). Despite this older people are less likely to be referred for psychological treatment (Frost et al., 2019, Nair et al., 2020)(5,6) and this effect increases with age – those over 85 years are 5 times less likely to be referred than 55-59 year olds (Walters et al., 2018)(7).

What prevents older people accessing psychological interventions and therapy?

Abridged from 'How to make IAPT more accessible to Older People - A Compendium'(8) and BABCP & Age UK NHS Talking Therapies Positive Practice Guide (2024)(1)

Myths about ageing are a barrier for both health and social care professionals and older people themselves, especially the belief that poor mental health is a natural consequence of the ageing process.

There is a perception that talking treatments are not as relevant for older people’s problems as younger adults and this can be on the part of the older person themselves or the health and social care professionals who work alongside them.

Stigma about accessing mental health exists across all age groups (Clement et al., 2015)(9) but can be particularly prevalent amongst the older population (Laidlaw & Knight, 2008)(10).

The types of mobility, frailty, sensory problems and cognitive changes that are more common in older people can be a barrier to treatment as these may require flexibility from services.

As more services are accessed or delivered remotely a lack of confidence in accessing services online (Age UK, 2021)(11) has become a barrier.

Being the carer for another older person is a considerable barrier for many older people accessing healthcare for themselves.

How to get older people’s psychological care on the agenda?

Routine liaison with and promotion of suitability of psychological services for older people to GPs, other primary care health and social care professionals, and voluntary agencies
Repeated promotion of and education about the service to community groups and services used by older people
Routine monitoring of referral sources to ensure continuity of referrals of older people
Active follow-up with referral sources that appear to have reduced their referral rates for older people
Offer awareness training on older people’s mental health needs to primary care health and social care professionals and voluntary sector providing psychological therapies and interventions
Adapting publications/materials so that both content and format are appropriate for older people

What helps overcome barriers to accessing treatment?

Age friendly self-referral or supported self-referral options
Enable people to opt-out of the service rather than opt-in (12)
Consider mobility and access when offering appointments e.g. can the person attend in person or would telephone/ Near Me be better. (Some services may be able to offer home visiting in some circumstances).
Where possible, arrange initial appointments by telephone and then follow-up this initial contact by written letter
Offer people reminder calls or texts (with their consent) so that appointments are less likely to be missed
Do not routinely discharge after a certain number of DNAs/cancelled appointments
Follow-up DNAs/missed appointments (if appropriate) by contacting GPs/carers/client in case these were due to memory problems, physical health problems, or illness
Use standardised outcome measures that are appropriate for older people
Liaise closely with other primary care health and social care professionals so that the client’s mental health needs are assessed and formulated within their wider health & social care context
Routinely administer service-evaluation questionnaires to clients to monitor service user perspectives on the service
Carry out service-user evaluation audits targeting older clients’ views to ensure these are taken into account when planning any service changes or developments

Therapeutic considerations

Abridged from BABCP & Age UK NHS Talking Therapies Positive Practice Guide (2024)(1) and ‘How to make IAPT more accessible to Older People – A Compendium’(8)

Whilst psychological therapists can be confident that older people who are offered standard psychological interventions and therapy are likely to benefit from treatment, a non-specialist may find older people’s presentation qualitatively different due to high levels of comorbidity, some age-linked complexity and longevity of problems. These are summarised by Sadavoy (2009)(13) as the ‘5 C’s’ of complexity, chronicity, comorbidity, continuity and context. A number of areas to consider in response to this are:

Working with long term conditions

Whilst chronological age and ill health are not directly correlated, long term conditions accumulate from middle age onwards. This means that conditions such as diabetes, COPD, Parkinson’s disease, and stroke are more common in older people and, as with younger adults, are associated with anxiety, depression, poorer mental health and quality of life. Where older people are not being seen for psychological therapies on a specialist long term condition (LTC) pathway it is important to place difficulties living with the LTC central to the formulation and intervention, as treatment outcomes may be improved when treatment protocols are adapted to address the challenges of having an LTC (Wroe et al., 2018)(14). Therapy that integrates mental and physical health needs may increase treatment acceptability and patient engagement (Panchal et al., 2020)(15), and self-management of long-term conditions (Wroe et al., 2018)(14).

(See Matrix: Delivering Effect Psychological Therapies and Interventions in Physical Health - content under development)

Working with mild cognitive changes

Mild cognitive changes in working memory, attention and processing speed are common in older people and are associated with age, fatigue, low mood, stress or anxiety, pain, long term conditions, and side effects of medication.

Boddington (2014)(16), outlines some practical approaches to working with MCI:

Schedule appointments for the time of day when the older person is most alert
Provide reminders of appointments
Provide capsule summaries throughout the session, as well as a summary of the session at the end
Encourage the older person to keep a record of the session (as local policy allows)
Repeat key concepts and skills within sessions and from session-to-session. Recap on what was discussed in the previous session at the beginning of the next session
Ensure there is flexibility to work at a slower pace. Check that you are going at an appropriate pace, slow down, and shorten the session length, if necessary. Offer shorter but more frequent appointments if helpful
Use worksheets that can be easily adapted for visual impairment
Where available use different coloured paper for home practice worksheets to help distinguish them from worksheets used within the session
Provide mid-week reminders to complete home practice

Working with family and systems

It is common for older people to have partners, family, informal or formal carers, and a range of health and social care professionals closely involved in their daily life. It is important to be open to involving others in the therapeutic work with the person or indeed to recruit them as co-therapists. For older people who live in care homes, sheltered accommodation, or who have packages of care at home it is important to consider wider working with these systems of care to help facilitate therapeutic work.

Wisdom and Life review

An obvious advantage of working therapeutically with older people is that they will have a lifetime of experience of overcoming challenges and learning to cope with difficulties. Producing an autobiographical life summary using a timeline (Laidlaw, 2021)(17) to examine the highs and lows of meaningful life events helps to recruit previous experiences of resilience and coping in facing current difficulties and foster self-compassion and acceptance. Although designed to be used in delivering CBT this approach is helpfully used across therapy with older adult. See BABCP & Age UK NHS Talking Therapies Positive Practice Guide (2024)(1) for more detail.

Selection, Optimisation with Compensation (SOC).

This approach helps the therapist and older person to concentrate on valued goals and adaptations that will help to achieve those goals. Selection, Optimisation with Compensation (SOC) promotes the idea of resilience and benefits of personal wisdom (Freund 2008; Freund & Hennecke 2015)(18,19) by encouragement to adopt an active coping strategy in the face of the challenges of ageing, e.g., bereavement, disability, and frailty. Selection of valued roles and goals is the first step in using SOC and focuses attention on tasks or activities that are most important to the older person and can be most realistically achieved. Optimisation involves skilled practice of the activity or task and can include role play in therapy. The final step in SOC is to adopt Compensatory strategies - considering current age-related challenges the older person is supported to modify their approach in order to compensate for a change in circumstances/abilities. Adopting this approach with clients enables the older person to continue to achieve valued goals by adapting to new circumstances and abilities. See BABCP & Age UK NHS Talking Therapies Positive Practice Guide (2024)(1) for more detail.

Trauma informed and responsive approach to care

Over a lifetime people often accumulate traumatic experiences e.g. adverse childhood experiences and experiences of violence/domestic abuse. Conceptualising these experiences as trauma may not be familiar to older people who may have generational beliefs that such experiences were just ‘part of life’. It may therefore be necessary to adapt language used during assessment, as well as to take more time to build trust and safety with an older person before they talk about traumatic experiences. As with working age adults, it is important to screen for trauma related symptoms of dissociation and PTSD (e.g.PCL-5), assessment requires awareness and adaptation for potential differences in PTSD experience and expression in older adults(20). (See PTSD section of the Matrix for more detail).

Working with Dementia

When working with people recently diagnosed with a dementia it is important to remember that this is a life limiting diagnosis, and the person faces a deteriorating picture. It is important to instil hope, and to recognise the person as they are now, a competent adult functioning in their life and in their relationships, families and community.

Therapeutic work should involve adjustment to the diagnosis and associated feelings of grief, loss and anger, and give an opportunity to explore the implications of the diagnosis for themselves, their future functioning and their relationships.

Structured therapy can be helpful, and the practical problem-solving approach of CBT is useful. Active participation e.g. taking notes, recording sessions (as local policy allows), using checklists, can help build confidence and keep therapy on track, (see also above tips for working with mild cognitive impairment).

Sessions may need to be shorter and slower paced, and it may be helpful to have partners, family, informal or formal carers attend sessions to help with recall. See BABCP & Age UK NHS Talking Therapies Positive Practice Guide (2024)(1) for more detail.

(For detailed evaluation of interventions in Dementia see Matrix Dementia section - content under development).

Supporting carers of people diagnosed with Dementia

There is good evidence that therapy can reduce psychological distress in dementia caregivers (Kwon et al 2017)(21). Therapists working with dementia caregivers should spend time at the start of treatment understanding the reasons that the carer is providing care, to explore the pre-morbid nature of the carer relationship and to avoid making assumptions about their relationship with the person with dementia. See BABCP & Age UK NHS Talking Therapies Positive Practice Guide (2024)(1) for more detail.

(For detailed evaluation of interventions in Dementia see Matrix Dementia section - content under development).

References

1.NHS Talking Therapies Positive Practice Guide Older People (2024). 2024; Available at: https://babcp.com/Therapists/Older-Adults-Positive-Practice-Guide. Accessed Feb 13, 2025.

2.Overview | Generalised anxiety disorder and panic disorder in adults: management | Guidance | NICE. 2020; Available at: https://www.nice.org.uk/guidance/cg113. Accessed Feb 13, 2025.

3.Overview | Depression in adults: treatment and management | Guidance | NICE. 2022; Available at: https://www.nice.org.uk/guidance/ng222. Accessed Feb 13, 2025.

4.Saunders R, Buckman JEJ, Stott J, Leibowitz J, Aguirre E, John A, et al. Older adults respond better to psychological therapy than working-age adults: evidence from a large sample of mental health service attendees. Journal of Affective Disorders 2021 -11-01;294:85–93.

5.Frost R, Beattie A, Bhanu C, Walters K, Ben-Shlomo Y. Management of depression and referral of older people to psychological therapies: a systematic review of qualitative studies. Br J Gen Pract 2019 -03;69(680):e171–e181.

6.Nair P, Bhanu C, Frost R, Buszewicz M, Walters KR. A Systematic Review of Older Adults' Attitudes Towards Depression and Its Treatment. Gerontologist 2020 -01-24;60(1):e93–e104.

7.Walters K, Falcaro M, Freemantle N, King M, Ben-Shlomo Y. Sociodemographic inequalities in the management of depression in adults aged 55 and over: an analysis of English primary care data. Psychol Med 2018 -07;48(9):1504–1513.

8.How to make IAPT more accessible to Older People: A Compendium. 2013; Available at: https://www.uea.ac.uk/f/185167/x/bfa0aef6a1/norwich-medical-school-how-to-make-iapt-more-accessible-to-old-people.pdf. Accessed Feb 13, 2025.

9.Clement S, Schauman O, Graham T, Maggioni F, Evans-Lacko S, Bezborodovs N, et al. What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med 2015 -01;45(1):11–27.

10.Laidlaw K, Knight B. Handbook of emotional disorders in later life: Assessment and treatment. New York, NY, US: Oxford University Press; 2008.

11.Digital inclusion and older people – how have things
changed in a Covid-19 world? 2021; Available at: https://www.ageuk.org.uk/siteassets/documents/reports-and-publications/reports-and-briefings/active-communities/digital-inclusion-in-the-pandemic-final-march-2021.pdf. Accessed Feb 13, 2025.

12.Prosser R, Dosanjh L, Jell G, Churchard A. Which older adults do not opt-in to Talking Therapies and why? the Cognitive Behaviour Therapist 2024 /01;17:e16.

13.Sadavoy J. An integrated model for defining the scope of psychogeriatrics: the five Cs. International Psychogeriatrics 2009 -10-01;21(5):805–812.

14.Wroe AL, Rennie EW, Sollesse S, Chapman J, Hassy A. Is Cognitive Behavioural Therapy focusing on Depression and Anxiety Effective for People with Long-Term Physical Health Conditions? A Controlled Trial in the Context of Type 2 Diabetes Mellitus. Behav Cogn Psychother 2018 -03;46(2):129–147.

15.Panchal R, Rich B, Rowland C, Ryan T, Watts S. The successful impact of adapting CBT in IAPT for people with complex long-term physical health conditions. the Cognitive Behaviour Therapist 2020 /01;13:e36.

16.Boddington S. CBT with Older People. In: Whittington A, Grey N, editors. How to Become a More Effective CBT Therapist: Mastering Metacompetence in Clinical Practice Newark, UNITED STATES: John Wiley & Sons, Incorporated; 2014. p. 208–224.

17.Laidlaw K. Cognitive behavioral therapy with older people. Handbook of cognitive behavioral therapy: Applications, Vol. 2 2021:751–771.

18.Freund AM. Successful Aging as Management of Resources: The Role of Selection, Optimization, and Compensation. Research in Human Development 2008 -05-21;5(2):94–106.

19.Freund AM, Hennecke M. On means and ends: The role of goal focus in successful goal pursuit. Current Directions in Psychological Science 2015;24(2):149–153.

20.Pless Kaiser A, Cook JM, Glick DM, Moye J. Posttraumatic Stress Disorder in Older Adults: A Conceptual Review. Clin Gerontol 2019;42(4):359–376.

21.Kwon OY, Ahn HS, Kim HJ, Park KW. Effectiveness of Cognitive Behavioral Therapy for Caregivers of People with Dementia: A Systematic Review and Meta-Analysis. J Clin Neurol 2017 -10;13(4):394–404.