What Is CBT? Cognitive Behavioral Therapy for Dementia

People with dementia often suffer from mental health conditions, symptoms that can lead to serious consequences.  These neuropsychiatric disorders can make it more difficult for them to carry out daily activities, while increasing their likelihood to be admitted to an institution. Their symptoms can also add stress for caregivers and loved ones. 

According to Sunil Bhar, professor of psychology at Swinburne University of Technology, people with dementia who are depressed may feel that they are losing touch of who they are, as they begin to lose their memories in the early stages of dementia. 

“They no longer feel a sense of mastery over their environment and identity,” said Bhar, who is also the co-director of the Wellbeing Clinic for Older Adults. About a third of those with dementia have depression and nearly a quarter to half of patients with Alzheimer’s and other forms of dementia suffer from anxiety.

Clinicians are now adapting the widely-used cognitive behavioral therapy proven effective for treating a host of mental health disorders from addiction to eating disorders. In an ongoing study, Bhar and colleagues conducted a clinical trial of cognitive behavioral therapy to treat the depression and anxiety of nursing home residents with mild to moderate dementia, testing techniques used in clinical practice. Participants’ families and nursing home staff also participated in the trial. 

Recalling memories

For residents who felt that they were losing sense of their identity, therapists would help them recall old memories.

“In dementia, most of the long-term memories are preserved far longer than the shorter ones,” Bhar said. “People might forget what they had for breakfast, but they remember very clearly the house they lived in when they were a child. They can piece together in minute detail what their room and neighborhood was like and who they lived with.” 

Though few people talked to those with dementia about anything beyond their short-term memories, Bhar explained: Conversations often focused on what they did yesterday or in the past week. 

By looking back at past experiences, people can in fact become ‘enlivened by suddenly remembering pieces of their life, which remind them about who they are,” Bhar said. “Identity is a collection of memories that reflect the missions and values of your life.” 

Interacting with loved ones

According to Bradley Rosenfield, associate professor at Philadelphia College of Osteopathic Medicine who is not involved in the study, decline in language abilities also poses a significant challenge for those with dementia as they may not be able to effectively communicate to others what they’re going through. Their decline in language skills can be frustrating for the people who interact with them, too.

“This complicates their life because they’re getting negative reactions from the people who used to support them,” said Rosenfield, who is also a clinical supervisor at Beck Institute for Cognitive Behavior Therapy. “As they go out into the world, they’re not getting positive reinforcement.” 

He pointed to the ‘cognitive triad’ theory, proposed by the pioneer of cognitive behavioral therapy Aaron Beck who described that people with depression possess negative thoughts about themselves, the world and the future. 

“With severe depression and dementia, we’re going to work on changing behavior,” Rosenfield added. “As we change [their] behavior, we’re hoping that modifies their beliefs of “nobody likes me” and “I’m helpless.” 

In the study conducted by Bhar and the team, participants who felt disconnected and had depression were encouraged to reach out to family members and friends. 

“People would visit them but they would have forgotten … They would say: “Nobody cares because I’ve received no visitors,” Bhar said. “Yet in the last week, they might have received 10 or 20 visitors.” 

Counsellors and staff put up white boards or other forms of memory aids where visitors would leave messages for residents to remind them: Contrary to their beliefs, friends and families did indeed visit them, and loved ones cared about them.  

Therapists and professional caregivers also encouraged people to participate in activities within their mental and physical abilities like listening to music or visiting an art museum. After all, researchers know that pleasant activities can help improve mood and decrease anxiety. In particular, music can transform those with dementia who are withdrawn into a more joyful state, reducing their agitation and even improving the mood of caregivers. 

How does CBT work for people with dementia?

Some researchers may argue that people with dementia are poor candidates for cognitive behavioral therapy, Bhar noted, as it involves talking, reflecting and changing behaviors. 

“If you don’t have control over your memories and perceptions, how on earth can you possibly engage with such therapy?” Bhar added. “Our experience, however, has been quite different.”

According to Nicholas Hope, a Doctor of Clinical Psychology student at the Philadelphia College of Osteopathic Medicine who was not involved in the study, people still have a level of self-awareness in the earlier stages of dementia since it is typically a slowly progressive syndrome. 

Clinicians are also using language and concepts that are easier to understand and follow, Hope added, who is also a professor of psychology at Temple University. A program designed by researchers at University College London involves giving dementia patients cards to take home, prompts that remind them to give pause when they feel as if their thoughts are spiralling into further anxiety. 

While cognitive behavioral therapy may be ideal for those in early stages of dementia and people with mild cognitive impairment, Hope said it is also effective for people with more progressed dementia by focusing on changing specific behaviors, boosting their confidence and well-being that can ease their depressive symptoms and delay cognitive decline. 

Potential benefits of CBT for the immune system

Cognitive behavioral therapy may not only improve people’s mental wellbeing, but it can also improve their immune systems and reduce inflammation, according to a study published last month. 

Researchers analyzed more than 50 clinical trials of various therapies for people with neuropsychiatric conditions and found that those who underwent such treatments had lower levels of pro-inflammatory cytokines. 

While cytokine proteins are crucial for healing wounds, they can also lead to chronic inflammation when the immune system revs into overdrive, increasing people’s risk for developing Alzheimer’s. 

“The primary job of the immune system is to protect the body from social, physical, and microbial threat. Therefore, it makes sense that our perception of the social environment would have the ability to change our immune system function,” George Slavich, Director of the UCLA Laboratory for Stress Assessment and Research, wrote in an email to Being Patient. 

Interestingly, cognitive behavioral therapy seemed superior to other forms of therapies: Its benefits for the immune system lasted for at least six months after treatment. 

According to Bhar, research examining how cognitive behavioral therapy can improve physiological functions is still in its early stages. Future studies are needed, Slavich added, to pinpoint whether changes caused by psychotherapy such as stress levels, sleep quality, diet or exercise are leading to improved functions of the immune system. 

Scientists also need to figure out whether changes in the immune system function due to psychotherapy can actually improve mental or physical health, Slavich said.  

CBT and dementia prevention

There is good evidence that a healthy lifestyle like eating a healthy diet, exercising and sleeping regularly can help reduce people’s risk for developing dementia. So Rosenfield and Hope along with their team are developing a pilot study to examine whether cognitive behavioral therapy and motivational interviewing can prevent or delay the onset of dementia by encouraging middle-aged adults to adopt healthier lifestyles.

The researchers will examine whether therapy may ease their depression and anxiety, and lead to changes such as their diet, sleep, activity levels and smoking habits. 

“Our goal is to use [cognitive behavioral therapy] and motivational interviewing to help people identify their deepest values and their cherished goals,” Rosenfield said, “and to frame treatment as a way to help them achieve their goals.” 

People may find a more satisfying life of meaning and purpose by striving for goals that align with their values, whether it is their friends, families or helping others, he explained: “That’s what makes life worth living.”