ADAPTATION OF IPT FOR COGNITIVE IMPAIRMENT
The clinical experience we gained in applying IPT to the MTLD-II cohort of older individuals, of whom 24% had clinically significant cognitive impairment, caused us to rethink the utility of traditionally delivered IPT for older patients who had features of both depression and cognitive impairment. Accompanying caregivers in this study frequently asked the IPT therapists for offhand management advice in the waiting room, which usually reflected their limited understanding of the identified patients’ executive dysfunction more than their memory loss or depression. Executive dysfunction can manifest as impairment in various higher-order cognitive functions such as insight, judgment, and complex problem solving presenting as impairments in one or more areas: social graces, initiative, planning, impulse control, empathy, and multitasking (shifting attention or focus without becoming confused). These abilities require multiple brain regions to communicate efficiently with each other. Thus, any brain disease that damages these neural circuits, such as strokes or Alzheimer’s disease, can produce executive dysfunction.
Besides being frustrated with the identified patient’s memory loss, caregiving family members frequently misread or misattribute signs of executive dysfunction as willful opposition, laziness, or even meanness. Caregiver reactions based on these misunderstandings can provoke further maladaptive responses and role disputes.
Researchers now define cognitive impairment on a spectrum from normal to so- called minimal cognitive impairment (MCI) (Lingler et al., 2006) to frank dementia, defined as significant memory loss that compromises functioning plus at least one other area of cognitive impairment. When meeting for the first time an older patient who has depression and some degree of cognitive impairment, it can be a puzzle to unravel how the depression and cognitive impairment (as well as any underlying medical illness) contribute to the clinical picture. Even facing memory impairment sufficient to impede a psychotherapy that builds upon work done in prior sessions, we concluded that the IPT approach was useful and viable with some modifications. We preserved the basic tenets of IPT such as the interpersonal inventory, ample psychoeducation, assigning the sick role, and establishing a focus with therapeutic efforts directed toward improving social role functioning. We saw a gap on the spectrum between psychotherapeutic approaches designed to help depressed elders and social casework for patients with cognitive impairment, with IPT-ci an ideal middle of that spectrum, especially in the early stages of cognitive impairment when caregivers frequently do not fully understand what they are observing.
Combining our IPT experience in MTLD-II with our psychiatric experience treating geriatric patients at a multidisciplinary treatment center (Benedum Geriatric Center), we formed a work group to discuss and test modifications of IPT. Since caregivers had many questions and were often beginning to take on more supervisory or helping roles with their cognitively impaired family members, we concluded it was crucial to modify IPT to integrate the caregiver into the IPT treatment process.
We define a caregiver as anyone who worries about, provides surveillance for, or assists an older individual for either cognitive decline or depression. We experimented with various refinements we then collectively named IPT-ci, for “cognitive impairment," and subsequently published an IPT-ci manual (Miller, 2009) as a guide for clinicians.
Table 14.1 outlines key modifications of IPT-ci.
We define “steady state” as the point when (1) both the identified patient and caregiver(s) are educated to their appropriate level of comprehension about depression and cognitive impairment/dementia, (2) a biomedical workup has determined potential medical causes for depression or specific subtypes of cognitive impairment, (3) trials of appropriate psychotropic medications have been attempted, (4) depressive symptoms and dementia-related problem behaviors have been minimized, and (5) quality of life has been maximized for the identified patient, taking cognitive status into account.
Social casework for cognitively impaired patients focuses on completing a diagnostic workup, assessing safety, finding helping services or new housing arrangements, and preparing for long-term contingencies like a nursing home or other long-term care facility. By virtue of its roots in psychotherapy, IPT-ci seeks to understand the patient’s presentation in the broadest context, including changes in social roles for not just the identified patient but caregivers as well. Traditional IPT techniques can be used insofar as a given older patient can collaborate with the psychotherapist, while specific IPT-ci techniques can help to bridge the gap of understanding between the identified patient and caregivers and can serve as a forum for joint or individual problem solving and role dispute resolution.
Absent a death that triggers grieving, identified patients who are keenly aware of and upset by their cognitive impairment are considered to be in a role transition from
Table 14.1. Comparing Traditional IPT and IPT-ci
IPT for Cognitive Impairment
Format: One-to-one patient- therapist visits, with rare involvement of significant others
Format: Full engagement of identified patient plus caregiver(s); flexible use of individual ; sessions with either the patient or
caregiver(s); option of joint problem-solving sessions as indicated
Focus: Reducing depressive symptoms
Focus: Assessment and treatment of both depressive symptoms and cognitive impairment/dementia
Duration: Twelve to sixteen
weekly sessions with contract for planned termination. Optional monthly maintenance IPT sessions (IPT-M) for patients at high recurrence risk.
Duration: Roughly weekly sessions to engage • patient and caregiver(s); complete workup for cognitive impairment and depression; goal of a “steady state”; follow-up visits spaced appropriately for the lifetime of the identified patient
normal cognitive ability to less so. Caregivers are recognized as often experiencing their own role transitions as they position themselves to supervise and provide more direct assistance: this position may prove uncomfortable, unwelcome, or even a role reversal. To understand the complete picture, which the identified patient may be unable to provide, the IPT-ci therapist must assess the caregivers’ ability to give care, understand other stressors the caregivers may be struggling with, engage them in education about what they are observing, and sometimes elicit their help to implement changes to improve the social role function of identified patients when the patients cannot implement such changes themselves.
Using techniques to indirectly benefit the identified patient by working with or through a caregiver obviously departs from traditional IPT, which focuses on the interface between the patient and the therapist, with infrequent input or visits from others in the patient’s interpersonal inventory. IPT-ci targets the interface between the identified patients and caregiver(s) who live with them or at least observe the effect of cognitive impairment on their daily function. Collaborative work with caregivers in addition to the identified patient allows the IPT-ci therapist a fuller understanding of the patient’s functioning as well as an opportunity to clarify, educate, and bridge gaps in understanding that can reduce future role disputes. Collaboratively seeking to implement changes that encourage better function and higher quality of life for the identified patient is the ultimate goal of IPT-ci, including but not limited to resolution of depressive symptoms.
Caregivers are not patients per se, even though they may benefit from the IPT-ci therapist’s efforts. Caregivers may require referral for their own therapy or other services., a subject we will return to after considering the evolution of the case of Mr. Jones, whose cognitive impairment has worsened to meet criteria for dementia.
CASE EXAMPLE: COMBINED PATIENT AND CAREGIVER INTERVENTION IN IPT-ci
Mr. Jones had made progress in his initial course of IPT focusing on his role transition facing retirement from his family business. The combination of antidepressant medication and IPT helped him feel better about deciding to continue his routine as long as he felt he was contributing in a meaningful way. During eighteen months of monthly maintenance medication management sessions, however, Mr. Jones began to complain more loudly that he felt unsure of himself and felt frustrated at work as it was now harder to contribute meaningfully, and that this made him feel more depressed. His Ham-D score rose to 22. Neuropsychological testing, performed as part of the research protocol at predetermined intervals over eighteen months, determined that Mr. Jones had declined from minimal cognitive impairment to dementia in a pattern that suggested probable Alzheimer’s disease. His MMSE score dropped from 25 to 18, and other cognitive test batteries declined. He wondered aloud if he should bother to go to the office anymore. He followed these thoughts with counterarguments that he would not know what to do with himself if he were no longer working.
After re-engaging with Mr. Jones and exploring this issue in depth, the IPT therapist recognized that Mr. Jones’ ability to continue working was in jeopardy. As Mr. Jones could not describe clearly how others around him were reacting to his now-obvious cognitive changes, the therapist offered to host a family meeting to explore this issue. Mr. Jones readily agreed.
In his prior IPT course, Mr. Jones had been a full partner in the treatment process despite mild memory loss consistent with minimal cognitive impairment. He had been able to consider the issue of retirement from several points of view (including the suggestions of his wife, children, and peers), and with his therapist’s help had explored his own feelings about what he really wanted for himself. Having decided to continue working for the time being, his mood improved and he seemed content.
As his cognitive impairment gradually but significantly worsened, eighteen months later Mr. Jones reported making work errors that were potentially costly to the company. This made him question his worth to the enterprise. A bigger problem than memory loss was his declining executive function. Good judgment and complex problem solving can be challenges in the business world even with fully functional brain capacity. Although from all indications Mr. Jones had once operated as a very effective chief operating officer, his dementia was taking a toll on his insight, judgment, problem-solving ability, and ability to grasp the “big picture.” His IPT-ci therapist could see that the problem was not confined to memory impairment: Mr. Jones’ ability to lead and to effectively delegate ongoing decisions was gone, as his wife and daughter confirmed.
How can one carry out IPT or any psychotherapy that requires intact memory to build upon prior work with a cognitively impaired patient? How can a therapist help a patient whose depression is relapsing from changes in his work ability and work relationships wrought by a brain disease like Alzheimer’s disease? The IPT-ci therapist seeks the best understanding possible of the problem (Mr. Jones’ declining ability to work effectively or contribute meaningfully) and to incorporate other sources of information (with permission) to help grasp the “big picture” more completely than the patient himself can, given his cognitive impairment. Although IPT-ci shares one goal of traditional IPT, to resolve depressive symptoms, the role of cognitive impairment in worsening Mr. Jones’ depression could not be ignored. IPT-ci confronts cognitive impairment head on to assess its severity and its disruption of the patient’s social roles. The IPT-ci therapist seeks to understand how the depression and the cognitive impairment conspire to reduce effective social role functioning while asking the question: “Who else might be willing to assist the identified patient to make meaningful changes to help reduce his or her depressive symptoms?” Traditional IPT might provide limited help to Mr. Jones in one-to-one weekly sessions if cognitive impairment limits his recall, insight, and understanding of the complex agendas of others around him in the workplace. If the IPT-ci therapist, understanding the common presentations of cognitive impairment, can gather enough information from all available sources to formulate a cogent assessment that includes the contribution of cognitive impairment to the depressive symptom picture, perhaps he or she can work realistically with the identified patient and involved caretakers. These techniques depart from traditional IPT by engaging and educating caregivers and potentially having separate or joint meetings with caregivers and the identified patient to orchestrate changes to help relieve the identified patient’s depression. IPT-ci deliberately shifts from a position of advocacy by working solely with the patient to a willingness to engage, educate, and enlist the assistance of interested caregivers who may help to reduce the identified patient’s depressive symptom burden.
Mr. Jones’ IPT-ci therapist invited all interested family members Mr. Jones wished to attend. He came to the meeting with his wife and his youngest daughter Gloria.
therapist: I want to welcome all of you. The purpose of this meeting is to better understand the issues surrounding your father and husband’s depression and the struggles he has expressed about how to pull back or retire from the business. sarah: I don’t work in the business, so I really can’t comment, but he has changed, and he doesn’t seem sure about what to do with himself anymore. mr. jones: I go to work every day, but I can’t seem to get a grip on what is happening.
We are short-staffed, and so I try to help out, but I make too many mistakes. therapist: Can you be more specific?
mr. jones: Yes. I get to working on drawings from a draftsman, and I forget where I put things. Sometimes the things get caught, but if they are missed and the steel goes out to a job site, it can be very expensive to have to cut and burn it to make it fit.
therapist: If I could ask a direct question, Mr. Jones, do you think your memory loss interferes with your ability to handle the jobs you do? mr. jones: Definitely. I spend half my day looking for things I misplaced. therapist: As I understand it, you have three children who work for this business, correct? One daughter manages the front office and oversees the orders and overall operation, your son manages the installation, and Gloria, who is here today, is the bookkeeper. Do I have that right so far? mr. jones: Yes.
therapist: You told me you have about twenty total employees and that you have built this business from scratch over thirty-five years and now have quite a loyal following of customers. mr. jones: Yes, that’s true.
therapist: You must be very proud of this business that you created and that is able to employ three of your children. mr. jones: Yes, I guess I am.
therapist: So you don’t want mistakes hurting your bottom line, but you also don’t want mistakes hurting the good reputation of the good-quality work that you have earned.
mr. jones: That’s correct.
therapist: Let me ask you this, then. Do you feel that your kids and your employees know what they are doing at this point, so that you don’t have to continue working in the way that you describe as increasingly harder for you to handle? mr. jones: Yes, they can handle it.
therapist: Then why do you still go to work if it is so hard for you? mr. jones: Habit, I guess. I wouldn’t know what to do with myself. I have friends who play golf every day for hours and are retired full time, and they sit around and bullshit about nothing. It never did much for me. Working has always been second nature to me since I was a young boy, and besides, the fabrication building is just one hundred yards from my house, so it’s just my routine to get up every day and go there. therapist: I see.
therapist: [To Gloria] Do you have an opinion about your father’s work and how it affects him emotionally?
gloria: It’s true, he does have trouble keeping up with projects, but we keep an eye on him, and we have taken more things away from him, but since we are shorthanded lately we’ve needed all the help we can get. I don’t think he is ready to just walk out of there and retire. This business is too much a part of him. . . . [hangs her head and pauses] There is something else. [looks at father] I’m sorry, but there are some personalities that are playing a role here. This person does not like to delegate either. She looks over his shoulder 24/7, and that’s fine . . . let’s just leave it that she doesn’t delegate either. This person should be here today. therapist: Are you speaking about your sister, then? gloria: Yes. She needs to be taken down a peg or two. sarah: It’s true. She is too bossy, and she needs to be settled down. therapist: I’m getting a picture of tension between you two sisters regarding how the business should be run. What about your brother? gloria: He has been going through a bad divorce and that is about all he can handle right now. therapist: I see.
therapist: [To Sarah] You mentioned that your older daughter needs to be settled down a bit. Is this something your husband would have handled in prior years that he is not seemingly able to do now? sarah: Yes, definitely.
therapist: [To Mr. Jones] Do you want to comment on that? mr. jones: It’s true. I’ve never been what you call a confrontative person. I never wanted to browbeat anyone. [Head hung, folding a tissue in his hands] therapist: Would you say that in previous years you felt more comfortable than you do now knowing the best decisions to make to run the company? mr. jones: Yes, that’s true. I just don’t seem to know what to do anymore. I spend my day going from one place to another, and I try to be helpful, but at the end of the day, I don’t seem to have accomplished much. therapist: [To Gloria] I’m getting the impression that you wish your father would be more authoritative towards your sister, who seems to be running the operation these days.
gloria: That’s right. No one voted her in to be CEO, but she acts like it. [Looks towards father] I’m sorry, but that’s the truth. mr. jones: You’re right. She can be bossy, but I just don’t know where to start sometimes, so I guess I haven’t been doing anything.
At this point it had become clear to me that in addition to memory loss, the preceding exchange demonstrates Mr. Jones’ executive dysfunction in his decreased ability to make authoritative decisions, which requires weighing many options, pros, cons, and projected outcomes. This has resulted in the de facto rise to power of his oldest daughter, who is absent, and the resentment expressed by his younger daughter, Gloria. It’s clear to me that the rest of the family was hoping Mr. Jones would “just take control and straighten things out and settle some people down,” meaning his eldest daughter, but has not done so due to executive impairment. I decided to try to: (1) provide psychoeducation about executive impairment; (2) acknowledge that the retirement issue is complicated by intrafamilial role disputes; and (3) acknowledge that the patient’s self-esteem is under great pressure from the perception that he should do something, yet he cannot figure out what that should be, and that his inability to “execute a plan” is due to executive dysfunction that the family has not yet recognized.
I see an opportunity within the remaining time to bridge the gap between the patient and the family, who have a distorted view of his current ability, and to seek opportunities for maintaining his self-esteem and helping him to minimize his depressive symptoms while coming to terms with his difficulties in conducting his business.
therapist: Mr. Jones, there seems to be some tension between your daughters about just how this business should be run, and your wife and Gloria seem to feel that the situation calls for you to do something about it. Do you sometimes feel pushed into the role of good cop, bad cop? mr. jones: Yes. It grieves me, but I don’t know what to do about it. therapist: If, for example, you were unable to be a part of this business any longer due to illness or some other reason, do you think there would be a shake-up after you left for good?
mr. jones: I would hope not, but I know there has been tension. therapist: [To Gloria] What’s your opinion?
gloria: Big time!! I want him to retire whenever he wants to, but if he walked out of the business tomorrow, I don’t think it would survive. therapist: Wow! Those are strong words.
mr. jones: That’s what I say. I’m aware that it’s not a good situation.
Now it’s clear that the current hot issue is less about mistakes he makes due to memory loss than that his perceived lack of leadership has left a void. It is clear to me that Mr. Jones cannot manage sorting through these issues on his own, and that he feels guilty in retreating from confronting them. Again, I am cognizant that Mr. Jones is the identified patient and that my role is to try to ameliorate his depressive symptoms by helping him cope with the role transition to partial or complete retirement as well as the role dispute he cannot effectively negotiate concerning business decisions. I decide to try some concrete suggestions and clarifications before ending the session.
therapist: If I might sum up a bit, it seems clear that you, Mr. Jones, are having a hard time at work these days for two reasons. Your memory loss impairs accuracy, and it’s a constant source of great frustration for you. When individuals suffer memory loss, other areas of brain function can suffer as well. Making the complex decisions required to run a business with all its demands means that many parts of the brain must work together efficiently to weigh the pros and cons of each decision, to actually come to a conclusion on a particular decision, and then to constantly evaluate how well that decision worked or did not work. Memory is one factor involved, but logical thinking, reasoning, and problem solving are also very important. I think it’s fair to say that these other areas have been weakened by the same disease process that causes your memory loss, namely probable early Alzheimer’s disease, as we discussed earlier. In other words, it’s not your fault that you cannot grasp the big picture and make strategic decisions as well as you did 10 or 20 years ago, it’s the result of the disease process your brain is suffering from. It’s just no longer possible for you to make hard decisions and to work as effectively and as efficiently as you once did. Are you all with me so far?
all: Yes, go on.
therapist: It also seems clear to me with regard to your business, that a succession plan has never been discussed or agreed to by all parties, am I correct? mr. jones: That’s true. It just seems to have evolved on its own. therapist: I would like to make some concrete suggestions that I think would be helpful here. Is that okay with you? mr. jones: Sure, go ahead.
therapist: I would first like everyone to understand, including those who are not here today, that Mr. Jones cannot be expected to make all the tough decisions anymore—through no fault of his own, as it’s due to Alzheimer’s disease. The same illness that has brought on memory loss has also robbed him of some decisionmaking capabilities. Does this make sense? all: Yes.
therapist: I think the time is not right to talk about formal retirement yet. He does not want it but also feels deeply frustrated with how many things aren’t going well. It’s not a simple matter of yes or no. Perhaps we need to allow him to gradually cut back and phase out at his own pace that feels right to him. gloria and sarah: We agree with that.
therapist: I also think that a serious discussion needs to take place among the children about how to best run the family business going forward. Am I right that no such discussion has taken place? gloria: That’s true.
therapist: The fact is, your father already struggles with memory loss, and now declining decision-making ability. If this is Alzheimer’s disease, as we suspect it to be, his ability to participate may be further compromised over time, not to mention his voiced wish to pull back to some degree or other. The result of all this is that the three of you sooner or later must find a way to cooperate, resolve your differences, and make the business thrive if it is going to continue to provide you with a livelihood for the long term. gloria: Yes, that’s true.
therapist: [To Gloria] Can you call a meeting of your siblings and have such a discussion? gloria: Yes.
therapist: Good. It really seems overdue, and waiting for your father to solve these issues has not worked satisfactorily up to now, right? gloria: You are correct.
therapist: [To Mr. Jones] Am I saying anything that does not seem right to you, Mr. Jones?
mr. jones: No, you’ve hit the nail on the head.
therapist: As it is soon time to stop for today, are there any questions any of you have? Have you found this family meeting to be helpful?” gloria and sarah: Yes.
therapist: Would you like to have a follow-up meeting to see how things are going? all: Yes.
therapist: Okay. I’ll see you, Mr. Jones, next week, and we’ll talk about a time for another meeting.