1. Modifying treatment for mildly impaired older adults. Felton Institute December 6, 2007 Patricia A. Arean, PhD The Over 60 Program Department of Psychiatry, UCSF

2. Learning Objectives  Understand the influences of cognitive impairment on practice  Recognize behaviorally when cognitive issues may be important  Tailor your work with these patients using some easy strategies (using psychotherapy as an example).

3. Mild Cognitive Impairment (revisited)  Cognitive Impairment: –Not just memory –Executive dysfunction –Language impairment –Attention –Information processing speed  30% to 70% co-occurrence with mental illness  Often under recognized  Can influence treatment outcomes

4. Mr. K  79 year old middle eastern man;  MMSE = 29  Well groomed, very well dressed, no belt  Complains of losing common items around house and at work  Very tearful, sudden onset, cannot tie to any trigger  Missed entire column on BDI  Narrative often goes off track, forgets questions asked of him, but remembers on cuing.

5. Mrs. Q  84 year old woman;  MMSE = 30;  Depressed after daughter moved from town;  Increased clutter in home;  Slightly disheveled in appearance;  Stopped many activities.

6. Psychotherapy

7. How psychotherapy works…  Psycho-education;  Reframing past and current experiences from negativistic to balanced/rational perspectives;  Mood induction;  Resolve problems causing depression.

8. Cognitive skills needed to make psychotherapy work…  Recall and recognition;  Attention and working memory;  Speed of information processing;  Problem solving skill;  Mental/cognitive flexibility;  Expressive and receptive language.

9. Recall and recognition  Depends on causes of memory impairments;  Cued recall approaches –Sequenced retrieval; –Paired learning; –Environmental prompts  Life review techniques

10. Attention and working memory  Shorter sessions;  Timing of sessions (am versus pm);  “Cue and review”;  Socratic questioning.

11. Speed of information processing  One problem at a time;  Cue and review;  More sessions over time.

12. Problem solving skill  Targeted interventions  Action planning  Brain storming techniques  Prompting

13. Expressive and receptive language.  Behavioral activation;  Simple, common terms;  Tie complex terms to familiar terms; Symbols don’t always work.