Cognitive-behavioral therapy (CBT) is a feasible and effective intervention for the treatment of anxiety in dementia patients, results of a new pilot study suggest.
Investigators, led by Aimee Spector, PhD, DClinPsy, from University College London, United Kingdom, found that CBT improved anxiety symptoms and significantly improved depression. Moreover, the intervention was cost neutral.
They now hope to take their results forward into a randomized controlled trial (RCT) to establish the efficacy of CBT in dementia patients with anxiety, for whom there are currently no effective treatments.
“This study helps to confirm that, despite cognitive impairments, people with dementia are able to learn new skills and engage in CBT, despite it previously being disregarded by many as a treatment for the ‘cognitively intact,’ ” Dr Spector told Medscape Medical News.
“The study also shows change in attitudes and feelings about their diagnosis and maintenance over time, suggesting the integration of new ideas and management strategies. Ultimately, I would hope that it would increase independence and reduce stigma – something that is much harder to achieve with drugs,” she added.
The research is published in the June issue of the British Journal of Psychiatry.
No Effective Treatments
Dr Spector pointed out that there is currently no effective treatment for anxiety in patients with dementia. However, anxiety is a major problem in this patient population, particularly at the point of dementia diagnosis, when individuals can become anxious and stop performing activities in their daily lives.
“CBT is something that has been shown to be effective in lots of other populations, but we know less of how adaptable it is for people who are cognitively impaired,” she said.
The researchers developed a CBT intervention manual for anxiety in dementia that is based on a systematic literature review, an expert review, a consensus conference involving 30 individuals, and a field test in three dementia patients.
The CBT is delivered in three phases, with the first involving building a collaborative relationship; providing psychoeducation about CBT and the impact of anxiety; self-monitoring; and identifying goals.
The second phase involves the application of change processes, including identifying strategies to help individuals feel safe, addressing unrealistic thoughts, and performing behavioral experiments. Phase 3 works toward ending therapy and developing a blueprint for the future.
Fifty dementia patients with anxiety and their caregivers were randomly assigned to either treatment as usual or 10 sessions of CBT plus treatment as usual. Outcomes and costs were assessed at baseline and at 15-week and 6-month follow-ups.
After adjusting for baseline anxiety and cognition, there was a nonsignificant difference in anxiety at 15 weeks on scores on the Rating Anxiety in Dementia scale between CBT patients and treatment-as-usual patients (mean difference in scores, -3.10). This was maintained at 6 months (mean difference in scores, -4.59).
There was a significant improvement in depression at 15 weeks with CBT vs treatment as usual on the Cornell Scale for Depression in Dementia (adjusted mean difference in scores, -5.37). This significant difference was maintained at 6 months.
Dr Spector commented that CBT is an attractive option for the management of anxiety in dementia, as opposed to drug therapy.
“I think it’s putting people in a position where they feel they have some kind of control over the things that they are worried about,” she said.
“With dementia, some of the anxiety is manifested quite physically, so people show anxiety through pacing around or behaving in certain ways, which might be traditionally what people might be treating with drugs,” she added.
“But a lot of people are saying: ‘I am nervous to go to the supermarket because I am worried that I am going to forget what I’m going to buy, or I’m going to bump into someone and not know their name.’ “
“I don’t think you can really treat something like that with drugs. It’s really about empowering people a bit more and maintaining people’s independence, which you can’t achieve with drugs.”
One of the striking findings from the study was that CBT was cost neutral overall. Although the costs, analyzed on the basis of a perspective toward healthcare and social care, were significantly lower in the CBT group vs the treatment-as-usual group between baseline and follow-up, this did not offset entirely the cost of CBT.
The adjusted mean cost difference between the CBT group and the treatment-as-usual group from baseline to first follow-up was £769.80 ($1201.50) per patient, which fell to £256.12 ($399.76) between first follow-up and second follow-up. Neither cost difference was significant.
Dr Spector believes that the cost neutrality seen in the current study should translate into cost savings in a full RCT.
“Obviously, with small numbers, it’s difficult to take that very far, but what we do know from the literature is that anxiety is so costly because patients are so much more likely to use services, they are more likely to be admitted to hospital, take medication, and have crises,” she said.
“I think there’s a good chance that, with a bigger trial, we might find some more substantial benefits in cost, which this study started to indicate.”
How is that larger trial progressing? “We’ve just applied for funding with the Health Technology Assessment Programme, so we’re really hoping that we will get [it],” Dr Spector replied.
“I think even without a full trial, because we have published the manual, it’s quite likely to be used clinically, but I think we really need that trial, particularly to establish what the effects are on cost,” she said.
If that trial yields the results that the current study would lead us to expect, what does Dr Spector see as the main barriers to implementing CBT for dementia patients with anxiety?
“I think the most important thing will be having enough people around to offer it,” she said, adding: “One of the problems we have now is often anxiety just goes untreated…. There are no treatments that we have evidence for, so people just don’t get anything.”
“So if we suddenly discovered that we have found something really effective, then we have to have the resources to actually offer that to people,” she added.
“Which isn’t a reason not to do it, but I suppose that’s the reality with anything…that you suddenly find that you have to treat something that you haven’t been treating.”
Important Research Question
Heather Snyder, PhD, director of medical and scientific operations at the Alzheimer’s Association, commented that testing whether CBT may be a potential intervention for dementia patients with anxiety is an “important research question.”
“Anxiety and depression in people with dementia is a challenge for both the individual and for their care partners, so having a way that it will support the individual with dementia and their care partner that may be beneficial would absolutely be something that would be welcome,” she told Medscape Medical News.
Nevertheless, she stressed that the current study was focused on examining the feasibility of conducting a larger study into the effectiveness of CBT in this patient population.
“I think we have to be a little bit careful in how we interpret what the benefit of cognitive-behavioral therapy is for anxiety and depression in people with dementia because, at this time, this is really a feasibility study of whether a larger study could happen,” Dr Snyder said.
Nevertheless, she added that the study “does underscore that in people with dementia, there is certainly a large number of people that are affected with anxiety or depression through the course of their dementia, and having a way to help those individuals as well as lessen the burden for their care partner is really important.”
Dr Snyder pointed out that one of the challenges is that no one person’s experience with dementia is the same, as it depends on the individual and their medical conditions and on their care support system.
In response, a number of nondrug interventions have been proposed for dementia.
“I’ve heard people anecdotally talk about engagement in music programs, art programs,” she said.
“The Alzheimer’s Association has chapter organizations all across the country that have a number of different programs to engage with individuals with dementia and/or their care partner in different activities,” she added.
The article presents independent research funded by the National Institute for Health Research under its Research for Patient Benefit (RfPB) Programme. The authors and Dr Snyder report no relevant financial relationships.
Br J Psychiatry. 2015:206:509-516. Abstract