IT'S THE PATH, NOT THE DESTINATION: LESSONS LEARNED FROM A PSYCHOSOCIAL INTERVENTION FOR HIGH RISK DEPRESSED, COGNITIVELY IMPAIRED OLDER ADULTS: Session 321

Abstract

Older adults with depression particularly those with mild to moderate cognitive impairment face many barriers to mental health treatment. Both intrinsic factors due to cognitive deficits and extrinsic factors such as recurrent medical hospitalizations, limit the effectiveness of psychotherapy. Furthermore older adults are a high risk population as rates of suicide are elevated especially in older men ≥85 years old. Psychosocial interventions for suicidal older adults are underdeveloped and do not take into account the role of cognitive impairment, specifically executive dysfunction. Homebound older adults have limited access to mental health care, even though 40% have a psychiatric illness including 29% who have dementia. This underscores an important intersection in the care of older adults with high medical illness burden, cognitive impairment and depression. Most of these older adults are cared for by family and other caregivers. While collaborative care models address untreated depression through integration in primary care settings, older adults with suicidal ideation may be deemed too high risk. And while most collaborative care models address depressive symptoms using Problem Solving Therapy (PST), older adults with depression and cognitive impairment may not be able to participate in PST nor attend weekly appointments due to multimorbidity. Furthermore traditional delivery models of psychotherapy focus on the individual and disregard the patient-caregiver dyad. In contrast, Problem Adaptation Therapy (PATH) has been efficacious in reducing depression and disability in older adults with varying degrees of cognitive impairment. PATH utilizes a simplified problem solving approach, employing compensatory strategies and environmental adaptations to bypass cognitive and functional limitations. Importantly, PATH involves the caregiver when appropriate and necessary. Preliminary data from the original PATH study showed that PATH reduces mild suicidal ideation in older adults. These findings led to a randomized clinical trial of PATH for Suicide Prevention (PATH-SP) and Supportive Therapy (ST) in middle-aged and older adults with varying degrees of cognitive impairment after discharge from a suicide-related hospitalization. In 2016, the Montefiore Home Care Geriatric Psychiatry Program (MHC-GPP) and Geriatric Neurology Center collaborated with Cornell Westchester on a pilot study to implement PATH in the Montefiore Medical Center (MMC). MMC serves the diverse communities in the Bronx and Westchester counties which have a high rate of poverty, untreated depression and medical comorbidities. In this pilot study, PATH is delivered in English and Spanish, both in the home or office, in order to provide a patient centered psychosocial intervention that acknowledges the complexity of coping with depression for older adults with high medical illness burden and cognitive impairment. Supervision for the PATH therapist is provided by an interdisciplinary team including a psychologist, geriatric psychiatrist and licensed clinical social worker with training in family therapy. The adaptation of PATH to fit the needs of high risk older adults with cognitive impairment has yielded important lessons beyond treatment efficacy that have implications for future clinical trials and mental health care delivery in this population. During this session, presenters will describe how PATH has been tailored to meet the varying needs of high risk older adults. Presenters will describe the PATH-SP trial for recently discharged patients. Presenters involved in implementation and supervision of PATH at MMC will discuss chart review findings and clinical case examples which illustrate themes and helpful strategies in the treatment of depression in older adults with high medical illness burden and cognitive impairment. Finally presenters will describe how PATH aligns with systemic family therapy theories through clinical case examples. Presenters will discuss how findings will inform the evolution of PATH and future clinical trials of psychosocial interventions to cognitive impaired older adults.