Demographic changes, restrictive rules for inclusion in managed healthcare insurance panels, and improvements in Medicare reimbursement are powerful factors attracting ever increasing numbers of psychologists in the United States to work with older adults. Current population trends are responsible for a pool of older clients; e.g., in 2006 the first of the Baby Boom generation meets the age requirement to enroll in Medicare as their primary healthcare plan. Recent census data indicate the fastest growing age group is the older adult age 85 and beyond. Directly linked to this group are adult children and family caregivers who seek psychological services and consultations for themselves as well as their parents. Also impacting psychology practice patterns are managed healthcare regulations that limit access to younger patients by restricting provider enrollment in many managed care panels, making it unlikely for new psychologists to participate. Added to the mix are low reimbursement rates from managed care plans, cutbacks in state Medicaid reimbursement for mental health services, and greater competition from other mental health professionals to provide assessment and psychotherapy. Such economic forces make it increasingly likely that larger numbers of psychologists who work in traditional private practice as well as integrated primary care settings will welcome referrals for older adults and consider marketing their services to this age group.
This paper illustrates a model of service delivery designed to meet the behavioral healthcare needs of community-residing older adults and their family members in a mid sized town in northeast Ohio. Founded by the senior author more than 12 years ago, the Center for Healthy Aging is a free-standing niche private practice with no outside funding. The center is modest in size, currently staffed with two full time clinical psychologists with a geropsychology specialty, one part-time therapist and occasional medical students or psychology trainees assisting in patient care. We offer focused, cost-effective behavioral health services that have proven to be well accepted by the consumer and are in compliance with Medicare and other third party payer regulations.
The array of services provided at our center includes cognitive/memory evaluations; individual, couple, and group psychotherapy; family consultations; health and behavior interventions; cognitive fitness/memory enhancement classes; and consultation and training programs for professionals. By working closely with local primary care physicians, we believe this is a service delivery model that can operate and thrive in many communities. The types of services illustrate opportunities open to psychologists who wish to expand their work to older adults, either as an adjunct to a general private mental health practice or by offering services to primary care practitioners in their offices.
Meeting the Psychological Needs and Requests of Older Adults, Their Families, and Their Physicians
Many common issues that motivate younger and middle age adults to consult a psychologist such as career and marital stress, parenting problems, or contemplation of divorce are not the typical ones that bring older adults to therapy (Cummings, 1998). Common problems or themes motivating older patients for treatment include social isolation and loneliness, traumatic events (Hyer & Sohnle, 2001), adjustment to retirement and/or relocation to a retirement community, bereavement and widowhood (Kastenbaum, 1999), adapting to physical changes and health problems (Schulz & Heckhausen, 1996), and coping with the disability of a spouse. Our experience at the Center for Healthy Aging corroborates that these issues are the most common reasons that our older patients seek treatment. Such stressors and life transitions can trigger depression and anxiety, with estimates of two million older adults having a major depressive illness and another five million with minor depressive symptoms that can impact physical health and quality of life (Alexopoulos, 2000; Steffens et al., 2000).
Although our center focuses on older adult care, to remain economically viable our clinicians also work with younger and middle age adults. However, approximately 65 to 70% of our current patients are over age 60. An analysis of the 139 new referrals of older adult patients, age 61 to 91, from January 2005 to March 2006, revealed that only a small percentage (5%) requested treatment on their own accord. Most referrals of older adults came from primary care physicians (over 80%), with adult children the next most frequent source of referral.
We believe that co-locating with primary care physicians is the most effective way to deliver behavioral healthcare services (O’Donohue, Cummings, & Ferguson, 2003). However, this has not been practical in our situation. Therefore, we do the next best thing: we work diligently to communicate, usually in writing, at the beginning of treatment with our physician referral sources, and we send progress notes several times during the intervention process. Feedback from our referral sources has been positive, and currently we have 18 primary care physicians who regularly refer to our center.
Because the majority of older adults referred to our center had not been consumers of mental health treatment in the past, our clinicians spend time explaining how assessments or behavioral health interventions can be of value to them and their families. We assure our patients that we will become partners with them, and treatment will not be protracted, but only what is necessary to reduce their emotional distress or help them to cope better with their medical problems. We have found that our older patients are cost conscious, even when they have minimal out of pocket costs (Hartman- Stein, 1999). This approach fits well with the Medicare requirement of providing only services that are medically necessary.
Cognitive/memory evaluations were the most commonly requested services (60% of new referrals). Suspected dementia or concerns about mild memory inefficiency prompted most referrals (83%). A smaller number of patients (11%) had a prior dementia diagnosis, but a consultation was sought to provide an opinion regarding the level of supervised care needed, recommendations for the least restrictive but safe living arrangement, or to develop a treatment protocol for a behavior troubling to the family, such as aggression, wandering, or withdrawal from activities. Our clinicians conduct a relatively brief cognitive assessment with such cases (one to two hours total including write up of the case) because the main focus is to aid the families in developing strategies to manage problematic behaviors. Finally, 5% of referred assessment cases were for legal purposes to answer questions regarding the individual’s capacity for financial or healthcare decision- making or the ability to make a valid contract such as a prenuptial agreement or change in a will.
About 25% of patients initially referred for cognitive/memory evaluations opted to choose one or more of the available treatments such as individual or group psychotherapy to mitigate depressive or anxious symptoms, interventions to assist with coping with early dementia, or for cognitive fitness/memory enhancement programs, a relatively new offering that is not covered by Medicare or other third party payers.
After referrals for cognitive assessments, the next largest referral category (27% of new patients ) was for psychotherapeutic treatment of psychiatric/psychological conditions such as unipolar depression, generalized anxiety, somatization disorder, bipolar disorder, or addiction to prescription medications and/or alcohol. One area of consultation and treatment unique to late life families is working to reduce conflicts between adult children and their cognitively intact or mildly cognitively impaired parents. In our experience such conflicts have arisen when the older adult wishes to re-marry in late life or develops an intimate relationship of which the adult child does not approve, an example of the proverbial role reversal conflicts between older parents and their often well-meaning, but sometimes overly intrusive children.
Best Practice Models and Evidence-Based Treatment for Geriatric Depression
Our model of service delivery emphasizes problem-focused, cost-effective behavioral health treatment approaches that fit well with the expectations of our patients, families, and primary care physician referral sources. Whenever possible, our clinicians use evidence-based treatments that are within the guidelines of the regulations of our Medicare carrier, a pragmatic and important issue when expecting payment for service from Medicare. A recent issue of Clinical Psychology: Science and Practice (Kendall, 2005) is devoted to a review of best practices for treatment of depression in older adults including a review of evidence-based psychotherapies for depression (Scogin, Welsh, Hanson, Stump & Coates, 2005). Scogin et al found evidence for the benefit of six treatments including behavioral therapy, cognitive behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy, and reminiscence therapy. Some Medicare fiscal intermediaries will not reimburse for reminiscence therapy or cognitive bibliotherapy as stand alone treatments (Hartman-Stein, 2005). However, it is possible to use reminiscence techniques within the context of cognitive-behavioral approaches to help patients reframe negative cognitions and alter self-deprecating thoughts. Cognitive bibliotherapy can also be used as a homework assignment when conducting cognitive therapy with older adults. In our treatment model for geriatric depression we have routinely used these evidence-based procedures with positive treatment results, and just as importantly, with good acceptance from our patients (Hartman-Stein, 1999).
Psychotherapy groups have been a mainstay of treatment in our model of service delivery. The modality of group therapy reaches a larger number of patients and achieves nearly equivalent therapeutic outcomes according to several reviews and research reports for adults of varying ages (Cheston, Jones, & Gilliard, 2003; Fuhriman & Burlingame, 1994; Piper & Joyce, 1996; Porter, Spates, & Smitham, 2004). Our anecdotal experience is that group treatment is a powerful adjunct to individual therapy for older adults experiencing depression, somatic preoccupation, grief, and social anxiety. We offer twice monthly sessions for 90 minutes, and optimally include about 6 people. Roughly 25% of our patients receiving individual psychotherapy also participate in group treatment. In addition to mitigating their presenting symptoms, the groups focus on helping patients learn to better regulate their affect, adjust to changes associated with aging, re-engage in life, and improve interpersonal relationships. Groups are on going with patients beginning or ending participation at diff e rent points, with treatment ending when their symptoms remit, rather than adhering to pre-set lengths of treatment protocols. The individualized decision regarding length of treatment is in keeping with the Medicare requirement of medical necessity. The groups usually include a mix of seasoned veterans who have shown considerable progress as well as new group members who are still unsure about what group therapy can offer.
The structure of each group session includes time for individual contact work when each person reports on his/her individual homework assignment and progress or problems in meeting negotiated and agreed upon goals. The group content and structure are based in part on ideas described in Group Cognitive Therapy: A Treatment Approach for Depressed Older Adults (Yost, Beutler, Corbishley, & Allender, 1986) as well as the concept of behavioral activation that emphasizes increasing the frequency of exercise such as daily walking and engagement in hobbies and family and community activities (Porter et al., 2004). The clinician leading the group can choose to emphasize either the cognitive elements of treatment such as recognizing and re-framing negative thoughts or behavioral activation depending upon the mix of patients present, allowing for clinical judgment, flexibility, and meeting the immediate needs of the patients.
Health and Behavior Interventions
A relatively small but growing number of patients in our practice come for help to cope with or manage a medical condition or chronic illness such as macular degeneration, Parkinson’s disease, chronic benign pain syndromes, weight loss following bariatric surgery, or orthopedic conditions requiring ongoing rehabilitation efforts. With the advent of a new category of health and behavior procedural codes open to psychologists, we are now able to treat individuals who do not meet the criteria for a psychiatric diagnosis but who need assistance adjusting to or complying with a previously diagnosed medical condition (Georgoulakis, 2002). About 10% of our patients currently receive such interventions, either in individual sessions, groups, or with family members present. Our health and behavior groups include the three characteristics of treatment, prevention, and management recommended by Cummings (2003) in his description of the ideal disease management protocol. Additional elements include an educational component, relaxation techniques, stress-management, exercise, and homework.
We have recently added to our repertoire of services interventions specifically tailored for patients experiencing memory impairment. One of our newer programs is a group intervention entitled Coping with Memory Loss, formed to meet the needs of our patients that have been newly diagnosed with either mild cognitive impairment or very early Alzheimer’s disease. Cheston (1998) reviewed the utility of directive groups in which the emphasis was on psychoeducation and encouraging patients to use strategies to facilitate adjustment to their memory impairment.
Our group health and behavior intervention is similar in concept, providing educational information about progressive dementia and teaching compensatory strategies such as the use of daily logs of activities and physical memory reminders. The group is highly structured, with almost half of the 90-minute time taken up with the presentation of information. The remaining 45 minutes is spent helping participants to problem solve particular challenges, checking progress on homework, and developing individual goals. Examples of some of the problems raised by group members include how to continue cooking for family and friends despite memory difficulties with familiar recipes; increasing compliance with medications; how to deal with embarrassing memory lapses during conversations; accepting common emotional reactions elicited by giving up driving; decisions about moving into assisted living; and how to talk assertively to health care professionals about their medical problems. Although this is still a relatively small part of our practice, we expect it to grow based on the enthusiastic reception from group members and their families.
Treatment Approaches for Co-Existing Depression and Dementia
Older adults referred for treatment for depression can prove to be especially challenging when memory functioning is declining. Depressive symptoms seem to appear more often in patients with milder levels of cognitive impairment (Burns, Jacoby, & Levy, 1990; Fischer, Simamyi & Danielczyk, 1990; Pearson, Teri, Reifler, & Raskinget, 1989). Patients in the early to moderate stage of dementia may present with depression, often exhibiting symptoms such as withdrawn behavior, anhedonia, lack of initiative, and a sense of hopelessness. Approximately 30% of patients diagnosed with Alzheimer’s Disease (AD) meet criteria for depression, and 20% of depressed patients have cognitive impairments severe enough to qualify as dementia. (Teri & Reifler, 1987; LaRue, D’Elia, Clark, Spar, & Jarvik, 1986.) After a decade of research it is generally recognized that depression and dementia coexist (Teri, McKenzie, & La Fazia, 2005). With such large overlap between depressive and cognitive symptoms, the need for treatment that can effectively address this complex combination of symptoms is clear. A significant number of our patients evaluated for memory complaints also meet the criteria for coexisting depressive illness, as is expected from research findings.
Largely as a result of advocacy efforts by Fried and the National Alzheimer Association, medical directors and CMS staff began to consider the value of psychological interventions for the patient with coexisting depression and dementia.
In addition to the psychological distress caused by depression, mood disorders in patients with dementia have been shown to lead to what Kahn describes as excess disability (1975). Increases in functional and behavioral problems for dementia patients with coexistent depression are well documented (Reifler & Larson, 1989). AD patients with depression show more vegetative signs, social withdrawal, loss of interest, feelings of guilt and worthlessness, and suicidal ideation as compared to non-depressed AD patients (Teri, Logsdon, & Uomoto, 1991). Even when researchers controlled for level of cognitive impairment, patients with coexistent depression and dementia showed greater impairment in activities such as eating, dressing, and bathing, compared to their non-depressed counterparts (Pearson, et al., 1989; Rovner, Broadhead, Spencer, Carson, & Folstein, 1989).
Research on caregiver distress also points strongly to the added burden of depression on family members. Effectively treating the depression of the memory- impaired patient decreases caregiver stress and burden.
Pharmacological treatment of depression remains the predominant treatment for older adults. This is not surprising given the fact that depression in older adults is usually addressed in the primarycare setting (Arean & Unutzer, 2003; Arean, Hegel & Reynolds, 2001). However, evidence for effectiveness of medication alone is not strong. A review of randomized controlled trails for antidepressant medication use by the elderly revealed five of eight published studies failed to show efficacy (Olin, Katz, Meyers, Schneider, & Lebowitz, 2002). Substantial benefit from a combination of medication and psychotherapy has been demonstrated by several studies (Bartels, et al., 2004; Unutzer, et al., 2000).
Payment Issues Impacting Therapy for Depressed and Memory Impaired Elders
Despite recognition that coexistence of depression and dementia are associated with morbidity, mortality, and excess disability as well as high levels of distress and depression in caregivers, treatment beyond pharmacotherapy has not been widespread (Teri et al., 2005). Payment issues commonly impact available treatment, and the coexistence of depression and dementia is a prime case in point. Prior to September 2001, Medicare carriers could automatically deny payment for mental health services if a patient had the diagnosis of a dementing illness in addition to a psychiatric condition such as depression. In September of 2001 the Centers for Medicare and Medicaid Services (CMS), released a memorandum disallowing the automatic denial of payment for psychological services solely because a patient has a dementia diagnosis (Hartman-Stein, 2001). Leslie Fried, an attorney and associate director of the American Bar Association’s (ABA) Commission on Legal Problems of the Elderly, was instrumental in bringing about this change. Because there is no cure for Alzheimer’s disease, Medicare carriers frequently denied services for these patients because the continuum of cognitive impairment was not considered. Payment was denied whether the patient was in the earliest detectable stage or in the most severe stage.
Largely as a result of advocacy efforts by Fried and the Alzheimers Association, medical directors and CMS staff began to consider the value of psychological interventions for the patient with coexisting depression and dementia. At the present time reimbursement for such services is decided on the basis of medical necessity, and not simply by diagnosis. This relatively recent change has opened the door for many more clinicians to work with this needy population of older adults.
Case Example: Millie
The case of “Millie” underscores the complexity of treatment of a patient with symptoms of memory impairment and depression as well as the need to bring together a virtual treatment team.
Millie was an 84-year-old Caucasian woman referred to our center by a geriatric psychiatrist because medication management and psychiatric hospitalization were ineffective in decreasing her severe depressive symptoms. The psychiatrist concluded she had characterological problems that made progress unlikely. He was on the brink of discharging her from his practice and recommending she be placed in a nursing home setting. Millie’s family wanted all treatment options exhausted before they followed this unwanted option. His referral for a geropsychological intervention was a last ditch effort prompted by the family.
Millie had a long history of recurrent depression, beginning in her mid 30s, but nothing as severe as she had been experiencing in the past year. Millie had moved into an assisted living facility shortly after the death of her husband, and though she made a good adjustment initially, she quickly lapsed into a deepening depression. In the nine months prior to treatment with us, Millie had been hospitalized psychiatrically four times for her depression, and she obtained religious-based grief counseling between hospitalizations. Over the year Millie voluntarily gave up driving, started using a walker, lost 30 pounds, stopped socializing with friends, and paid less and less attention to her appearance. Her preference was to stay in bed all day and have her meals brought to her room.
During the first session with us Millie was highly reluctant to work with us, openly doubting that there was much we could do for her. However, she was also very fearful that her assisted living facility would kick her out if she did not start participating more actively in the community, and therefore she agreed to give us a try if we could help her with this goal.
During her first session she identified the trigger to her most recent depressive episode as the loss of her caregiving role. She had been the primary caretaker for her husband during the last years of his life. Though he was very sick, and she believed that it was his time to go, she truly missed feeling useful without her caregiver responsibilities. Once she moved into her assisted living apartment she gradually gave up taking care of herself, and now felt that she was making little contribution to anyone or anything. She expressed guilt that she was ignoring her friends, but at the same time was unable to force herself to behave any differently.
By the end of this initial session Millie agreed reluctantly to attend a combination of individual and group sessions. Our initial treatment approach was to use a fairly standard cognitive-behavior treatment protocol in which the therapist (the second author) challenged her negative automatic thoughts and helped her generate a more positive and realistic view of her strengths and abilities. In addition we assigned behavioral homework such as tracking her daily activities and obtaining an exercise schedule of classes at the facility. Millie returned for her second appointment a week later and appeared worse. Her hair and clothing were unkempt, and she wore no makeup as she had during the first session. She had completed none of her agreed upon homework. She berated herself for this failure, but was unable to explain the reason for the homework noncompliance. Further exploration of her day-to-day life revealed that she had reduced her bathing to once per week, had taken all of her meals alone in her room, and had refused to attend family gatherings. In addition, she revealed that she was increasing her frequency of anxiolytic use, up to three times per day, despite feeling very sleepy and whoozy. Millie was unclear why she took and the increased the odsage of this medication, reporting that she asked for it, and “the nurses just bring it to me.”
Although neither her family nor her psychiatrist suspected memory impairment, we questioned if cognitive impairment could be negatively impacting Millie’s recovery. During the first three sessions of treatment she showed no signs of benefiting from the cognitive strategies and instead was getting progressively worse. In addition, a family member mentioned that Millie had recently starting misplacing things in her apartment and then reporting them as stolen. After consulting with Millie’s psychiatrist we conducted a cognitive evaluation in order to have a more complete picture of her cognitive capacity.
As suspected, cognitive testing revealed mild but significant impairment in verbal recall skills, conceptualization, and executive functions such as divided attention and ability to maintain a cognitive set.Millie’s overall performance, a family history of dementia, and inability to recover from her most recent episode of depression, despite medication and behavioral treatment strategies, suggested to us that she was exhibiting the early signs of dementia. Exacerbation of depression, continued social withdrawal, and difficulty initiating behavior are frequently seen in the very early stages of dementia and can make treating depressive symptoms very difficult. In addition, Millie had a recent history of benzodiazepine use that was complicating the diagnostic picture.
This information about possible mild declines in Millie’s cognitive abilities led us to alter our treatment plan in several ways. Though Millie was certainly capable of participating in structured therapy sessions, her ability to initiate new behaviors outside of the session and organize her daily activities was impaired. Also because of her conceptualization deficits and the failure of previous supportive grief therapy, we changed the focus of treatment from a cognitive-behavioral protocol to a behavioral activation treatment approach alone. However, in order to successfully increase her activity level we advised the family that daily prompting of her efforts and reinforcement of any successes would be required. Her assisted living community was not able to provide the one-on-one attention we believed was necessary, so we suggested the family hire a paid caregiver/companion who could prompt, reinforce, and accompany Millie to a number of activities each day. The family found an appropriate individual through their church, and agreed to hire the companion for approximately 20 hours per week. Fortunately Millie and her new companion quickly established a good relationship.
We conducted one session training the paid companion about positive behavioral reinforcement techniques. In addition, the paid companion attended all subsequent therapy sessions with Millie and was integral in developing goals and implementing the treatment plan outside of session. Millie helped to decide which activities she would accomplish each week, and the therapist recorded them on an index card during each session. Examples of weekly goals, which the companion tracked in a notebook, included attending two meals per day in the dining room, increasing the number of showers per week, reducing the frequency of anxiolytic use, fixing her own breakfast in her room, and taking a trip to a local shopping mall to purchase new make-up and clothing. As some of these new behaviors became part of Millie’s routine, she required less prompting from the companion. For example, after several weeks, Millie began walking herself to the dining hall before her companion even arrived “so no one would take my favorite seat.”
In addition to the individual sessions, Millie participated in group therapy in our practice. The group was comprised of other women similar in age to Millie who had lost their husbands in the past few years. An important aspect of this group treatment was that other group members saw Millie more capable than she viewed herself. They complimented her about her extensive past volunteer work. Millie and the other widows in the group developed a positive relationship and slowly she began to see herself more positively through direct and authentic feedback of her peers.
One additional component to the behavioral activation approach was to convey in writing after each session brief instructions for the staff at the assisted living facility. We reinforced them for patiently prompting Millie to follow her homework assignments. Added encouragement from the staff appeared to be an essential component for the treatment to be successful.
In 12 sessions spaced over four months, Millie’s depression has reduced to a mild level of severity. Although she is not ready for discharge from active treatment, and fluctuations of mood and functioning are likely given the initial severity of symptoms, her current functional status and rate of improvement have pleasantly surprised her family, psychiatrist, and staff at the assisted living facility.
As a footnote, although many families may not have financial resources to hire an additional caregiver for a similarly withdrawn and depressed patient, volunteer friendly visitor services are available in many communities. This particular case example illustrates that in order to lessen severe depressive symptoms in a treatment-resistant memory impaired and depressed patient, therapists must be creative, flexible in approach, and persistent. Involving numerous support staff is a critical element for success.
Cognitive Fitness Activities
The mission statement of our center encourages innovative programming that goes beyond clinical work and encompasses prevention, education, and the promotion of active lifestyles for older adults. Supporting this mission, we offer a variety of activities as part of our Brain Booster Club. Participants can choose from a variety of activities including book discussions about positive approaches to aging, lectures on health and spirituality, memoir writing classes, crossword puzzle groups, memory enhancement training, and classes to improve spelling and vocabulary skills.
The book club features readings related to successful aging and improving memory skills. For some meetings, guest speakers with special interest or expertise in a particular book are invited to lead the discussions. Books featured in the monthly meetings have included The Wisdom Paradox (Goldberg, 2005), The Memory Bible (Small, 2002), Still Here (Dass, 2000), and The Mature Mind (Cohen, 2005).
The memory enhancement training, a particularly popular program, was offered because many middle aged and older adults worry about losing their memory skills. The series of four classes teach participants research-based techniques and principles including the use of physical reminders, relaxation strategies, imagery techniques, rehearsal, chunking, sensory activation strategies, self-instruction, and the creation of mnemonic devices (Scogin & Prohaska, 1993). The small group format for the class allows for active involvement and social interaction among all members.
Other popular classes have included a seminar entitled, Eating for a Healthy Brain. A medical nutrition therapist from the Texas Heart Institute led the program and incorporated material from The Better Brain Book (Perlmutter, 2004) and Healthy Aging (Weil, 2005). Sampling recommended foods such as dried blueberries, green tea, and sunflower seeds added to the lively social atmosphere of the seminar.
The centerpiece of the Brain Booster program is a Senior Spelling Bee, brought to this area by the senior author that is co-sponsored by a local community mental health organization. The senior author has developed a course called SeniorSpeller® for middle age and older adults to learn challenging words based upon memory enhancement techniques. We have also conducted pilot research on these efforts to learn more about the effectiveness of the memory strategies (Hartman-Stein, Dunlosky, & McClure, 2005). Our first annual Senior Bee was highly competitive last year, with contestants successfully spelling words such as aebliskive, ditokous, and gymkhana. A pre-bee reception and media coverage made the evening of the Bee an exciting cognitivesocial community activity. This event received wide spread media coverage that emphasized the contribution a geropsychologist can make to the cognitive health of older adults.
In conclusion, our model of behavioral health service delivery to older adults has been well accepted by several “stakeholders” including older adult clients, their families, primary care and specialty physicians, and staff in retirement communities. In addition, it enables us to be creative and innovative in our work of mitigating mental health problems, improving coping with difficult life transitions and medical conditions, and enhancing vitality in late life.
Paula E. Hartman-Stein, Ph.D. is a clinical geropsychologist at the Center for Healthy Aging in Kent, Ohio, a behavioral healthcare practice she began in 1994, as well as Director of Geriatric Psychology at Summa Health System in Akron. Her academic affiliations include Adjunct Associate professor at the Dept of Psychology at Kent State, Clinical Assistant Professor of Psychology at the Northeastern Ohio Universities College of Medicine, and Senior Fellow at the University of Akron’s Institute for Life Span Development and Gerontology. Her Ph.D. is from Kent State, and she obtained the Interdisciplinary Geriatric Clinician Development Award through Case Western Reserve University. For the past 8 years Dr. Hartman-Stein has contributed regularly to The National Psychologist newspaper. Other publications include the book, Innovative Behavioral Healthcare for Older Adults: A Guidebook for Changing Times, and she is one of the authors of the APA’s Guidelines for Psychological Practice with Older Adults. She is past-president of APA’s section of clinical geropsychology. Her current research interest is designing cognitive fitness programs for older adults. Dr. Hartman-Stein has been a Registrant since 1983.
Leslie E. McClure, Psy.D., received her doctorate in Clinical Psychology from the Chicago School of Professional Psychology and recently completed a Geropsychology Post-doctoral Fellowship at Summa Health System. She is currently associate director of the Center for Healthy Aging. Dr. McClure provides cognitive assessments, psychotherapy, and consultations to older adults and their families. She also offers innovative programs for increasing cognitive vitality such as computer-based activities for adults. She is available for consultation to local adult day centers regarding management of problem behaviors for patients with memory impairment.
Alexopoulos, G. S. (2001). Interventions for depressed elderly primary care patients. International Journal of Geriatric Psychiatry, 16(6), 553-559
Arean, P. A., Hegel, M. T., & Reynolds, C. F. (2001). Treating depression in older medical patients with psychotherapy. Journal of Clinical Geropsychology, 7, 93-104.
Arean, P.A., & Unutzer, J. (2003). Inequities in depression management in low-income, minority, and old-old adults: A matter of access to preferred treatments? Journal of the American Geriatrics Society, 51(12), 1808-1809.
Bartels, S. J., Dums, A. R., Oxman, T. E., Schneider, L. S., Arean, P. A., Alexopoulos, G. S., et al. (2003). Evidence-based practices in geriatric mental health care: An overview of systematic reviews and meta-analyses. Psychiatric Clinics of North America, 26, 971-990.
Burns, A., Jacoby, R., & Levy, R. (1990). Psychiatric phenomena in Alzheimer’s disease: Disorders of mood. British Journal of Psychiatry, 157, 81-86.
Cheston, R. (1998). Psychotherapeutic work with dementia: A review of literature. British Journal of Medical Psychology, 71(3), 211-231.
Cheston, R., Jones, K., & Gilliard, J. (2003). Group psychotherapy and people with Dementia. Aging & Mental Health, 7, 452-461.
Cohen, G. (2005). The mature mind. New York: Basic Books.
Cummings, N. A. (1998). Approaches to preventive care. In P. E. Hartman-Stein (Ed.), Innovative behavioral healthcare for older adults: A guidebook for changing times (pp. 1-17). San Francisco: Jossey-Bass.
Cummings, N. A. (2003) Advantages and limitations of disease management: A practical guide. In N. A. Cummings, W. T. O’Donohue, and K. E. Ferguson (Eds.), Behavioral health as primary care: Beyond efficacy to effectiveness: Vol. 6. Cummings Foundation for Behavioral Health: Healthcare utilization and cost series (pp. 31-44). Reno, NV: Context Press.
Dass, R. (2001). Still here. New York: Riverhead Books.
Fischer, P., Simamyi, M., & Danielczyk, W. (1990). Depression in dementia of the Alzheimer type and in multi-infarct dementia. American Journal of Psychiatry,147, 1484-1487.
Fuhriman, A., & Burlingame, G. M. (1994). Measuring small group process: A methodological application of chaos theory. Small Group Research, 25(4), 502, 519.
Fogler, J. & Stern, L. (2005). Improving your memory. How to remember what you’re starting to forget (3rd ed.). Baltimore: Johns Hopkins University Press.
Georgoulakis (2002) Six new CPT codes to be implemented in 2002. The National Psychologist, 11 (1), 21.
Goldberg, E. (2005). The wisdom paradox: How your mind can grow stronger as your brain grows older. New York: Gotham.
Hartman-Stein, P.E. (1999). Adapting to managed behavioral healthcare for older adults: A practitioner’s perspective. Journal of Geriatric Psychiatry, 22, 43-61.
Hartman-Stein, P. (2001). Federal agency to begin reimbursing long-denied diagnosis for dementia. The National Psychologist, 10, 17.
Hartman-Stein, P. (2005). An impressive step in identifying evidence-based psychotherapies for geriatric depression. Clinical Psychology: Science and Practice, 12, 238-241.
Hartman-Stein, P.E., Dunlosky, J., & McClure, L. (2005). Enhancing spelling skills and verbal recall of older adults. Paper presentation at Ohio Association of Gerontological Educators Professional, Scientific, and Student Conference on Aging. Aurora, OH.
Hyer, L. A., & Sohnle, S. J. (2001). Trauma among older people: Issues and treatment. Philadelphia: Brunner-Routledge.
Kendall, P. C. (Ed.). (2005). Clinical Psychology: Science and Practice, 12(3).
Kahn, W. (1975). The mental health system and the future aged. Gerontologist, 15, 24-31.
Kastenbaum, R. (1999). Dying and bereavement. In J. C. Cavanaugh, & S. K. Whitbourne (Eds.), Gerontology: An interdisciplinary perspective (pp. 155-185). New York: Oxford Press.
LaRue, A., D’Elia, L. F., Clark, E. O., Spar, J.E., & Jarvik, L. F. (1986). Clinical tests of memory in dementia, depression, and healthy aging. Journal of Psychology and Aging, 1, 69-77.
O’Donohue, W. T., Cummings, N. A., & Ferguson, K. E. (Eds.). (2003). Behavioral health as primary care: Beyond efficacy to effectiveness: Vol. 6. Cummings Foundation for Behavioral Health: Healthcare utilization and cost series. Reno, NV: Context Press.
Olin, J. T., Katz, I. R., Meyers, B. S., Schneider, L. S., & Lebowitz, B. (2002). Provisional diagnostic criteria for depression of Alzheimer disease: Rational and background. American Journal of Geriatric Psychiatry, 10, 129-141.
Pearson, J., Teri, L., Reifler, B., & Rasking, M. (1989). Functional status and cognitive impairment in Alzheimer’s Disease patients with and without depression. Journal of the American Geriatrics Society, 39, 1117-1121.
Perlmutter, D. (2004). The better brain book. New York: Riverhead Books.
Piper, W. E., & Joyce, A. S. (1996). A consideration of factors influencing the utilization of timelimited, short-term group therapy. International Journal of Group Psychotherapy, 46(3), 311-328.
Porter, J. F., Spates, C. R., & Smitham, S. (2004). Behavioral activation group therapy in public mental health settings: A pilot study. Professional Psychology: Research and Practice, 35, 297-301.
Reifler, B. V., & Larson, E. (1989). Excess disability in dementia of the Alzheimer’s type. In E. Light & B. Lebowitz (Eds.), Alzheimer’s disease treatment and family stress: Directions for research (pp. 363-382). Rockville, MD: U.S. Department of Health and Human Services.
Rovner, B. W., Broadhead, J., Spencer, M., Carson, K., & Folstein, M. F. (1989). Depression and Alzheimer’s disease. American Journal of Psychiatry, 146, 350-353.
Schulz, R. & Heckhausen, J. (1996). A lifespan model of successful aging. American Psychologist, 51(7), 702-714.
Scogin, F., & Prohaska, M. (1993). Aiding older adults with memory complaints. Sarasota, FL: Professional Resource Press/Professional Resource Exchange, Inc.
Scogin, F., Welsh, D., Hanson, A., Stump, J., & Coates, A. (2005). Evidence-based psychotherapies for depression in older adults. Clinical Psychology: Science and Practice, 12, 222-237.
Small, G. (2002). The memory bible: An innovative strategy for keeping your brain young. New York: Hyperion.
Steffens, D. C., Skoog, I., Norton, M. C., Hart, A. D., Tschanz, J. T., Plassman, B. L., et al. (2000). Prevalence of depression and its treatment in an elderly population:The Cache County study. Archives of General Psychiatry, 57(6), 601-607.
Teri, L., Logsdon, R., & Uomoto, J. (1991). Treatment of depression in patients with Alzheimer’s disease. Therapist manual. Seattle: University of Washington School of Medicine.
Teri, L., McKenzie, G., & LaFazia, D. (2005). Psychosocial treatment of depression in older adults with dementia. Clinical Psychology: Science and Practice, 12, 303-316.
Teri L., & Reifler, B. V. (1987). Depression and dementia. In L. Carstensen & B. Edelstein (Eds.), Handbook of clinical gerontology. Pergamon general psychology series (pp. 112-119). New York: Allyn & Bacon.
Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W., Hunkeler, E., Harpoole, L., et al. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trail. The Journal of the American Medical Association, 288, 2836-2845.
Weil, A. (2005). Healthy aging: A lifelong guide to your physical and spiritual well being. New York: Knopf.
Yost, E. B., Beutler, L. E., Corbishley, M. A., & Allender, J. R. (1986). Group cognitive therapy: A treatment approach for depressed older adults. University of Arizona:Pergamon Press.