Cognitive Behavioural Therapy (CBT) for anxiety in dementia:

1. Cognitive Behavioural Therapy (CBT) for anxiety in dementia: A qualitative study exploring the CBT experience of dementia patients and their carers Mary Opoku (2012)

2. Background – Dementia • 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.

3. Background – Anxiety in 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

4. Cognitive Behavioural Therapy (CBT) • 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.

5. CBT as a treatment • 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.

6. CBT as a treatment Three case studies examining CBT for anxiety in dementia (Kraus et al, 2008) found: • Changes in thoughts, feeling and behaviours • Clinical reduction in anxiety • Improved mood • Participation in pleasurable activities • Reduced insomnia

7. The Main Trial 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

8. 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

9. This Project 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

10. 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

11. Method 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

12. Method Participants: • Caucasian/ white British • 6 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)

13. The Qualitative Interview 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

14. Analysis • 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.

15. 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

16. 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…

17. Preliminary results • 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

18. Implication 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.

19. References 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