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Problem Adaptation Therapy or PATH for Dementia

By Haines EasonNovember 19, 2021
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Studies show that seniors living with dementia or other memory-related conditions have up to a 40% increased risk for major depression. However, depression in this population is hard to treat. Less than half of seniors dealing with both memory conditions and depression respond to antidepressants.

Recent research shows that Problem Adaptation Therapy, or PATH, may ease depression in people with forms of dementia better than supportive therapy and can enhance the limited effects of antidepressants in this population. Whether your loved one is receiving care at an assisted living facility, a memory care facility, or home, PATH can help them feel happier and more in control of their lives.

“What we’re doing is focusing on the person and empowering them, making them feel like they have a say in how they will be treated,” says Dr. Dimitris Kiosses, a psychologist and director of the Emotion, Cognition, and Psychotherapy Lab at Weill Cornell Medicine. In other words, much of PATH’s success comes from its focus on the senior rather than the caregiver, which makes it unlike previous therapies. After originally using PATH as an in-home therapy, Kiosses’ team is now developing specialized caregiver training for PATH use in memory care communities.

Read on to learn more about how PATH works, how to use PATH techniques at home, and how to speak to your loved one’s memory care community about adopting this treatment.

What is Problem Adaptation Therapy?

PATH helps memory-impaired seniors with depression self-soothe by reducing negative emotions associated with stressors, which enables them to cope with stressful situations and prevent emotional crises and outbursts. Seniors learn to lead this person-centered, problem-solving approach with help from their caregivers.

PATH is flexible psychology that adapts its goals to the individual person. Therapists first help seniors and their caregivers figure out how the living environment causes negative emotions. Then, the senior, caregivers, and therapists find ways to modify the environment to reduce the senior’s negative emotions based on the senior’s preferences. Changes to the senior’s living spaces could include removal of stressful objects, like a photo of someone they have trouble remembering. The strategic use of calendars, directional signs, and storage for everyday essentials — like keys or shoes — can also help seniors feel more aware and in control of their lives.

While caregivers play a big part in changing the senior’s environment, the senior ultimately determines the way forward, which Kiosses says is essential to PATH.

How does Problem Adaptation Therapy work?

PATH has five steps, which follow the five-stage process model of emotional regulation developed by Dr. James Gross at Stanford University. Each of the five PATH stages has a goal, and each stage builds on the previous one. How you adjust one stage will affect the others and the ultimate emotional outcome. Each goal gives the senior and their caregiver an empowering approach to emotional situations.

PATH begins with an assessment of the environment or situation causing anxiety to your loved one and identifies what is overwhelming them. When you learn how your loved one experiences the environment and situations, you can help them cope with their negative feelings linked to those spaces or situations.

To prevent anxiety, the senior and their PATH caregivers make specific changes to the surroundings to avoid an emotional crises in the first place. When the space or situation is not easily controlled and still causes anxiety to your loved one, PATH training teaches the caregiver to work with the senior to use preestablished coping mechanisms.

PATH’s five stages of emotional regulation are as follows:

1. Situation selection. The goal of this stage is to identify the people, environmental factors, or situations that are upsetting to your senior loved one. Here, caregivers and staff can encourage seniors to identify their feelings within troubling situations, urge them to point out specific details that may be a trigger, and help them develop a plan to feel better.

2. Situation modification. In this stage, the senior and their caregivers work together to remove or avoid the stressful detail in the senior’s situation. Together, they also plan ways to change the situation for the better in the future. Tools like calendars, notes, and signs can help your loved one prepare for stressful situations and maybe avoid them altogether.

3. Attentional deployment. The goal here is for the caregiver to shift the senior’s attention away from the stressful detail during a crisis moment. Visual tools, instruments, and preplanned verbal cues (e.g., pointing to a favorite picture on the wall and encouraging reminiscence) can help the senior focus on the positives during a stressful time.

4. Cognitive change. In this stage, the caregiver encourages the senior to focus on the positive details of life, rather than dwelling on negatives. If the senior is regularly upset about situations, remind them of their strengths, skills, or other positive qualities to help elevate their mindset beyond limitations. Help them reflect on positive memories, look to awards or other mementos, and engage in activities they like.

5. Response modulation. The goal here is to identify your loved one’s emotions during a crisis and help them calm down. Caregivers can try the following to help de-escalate a crisis:

  • Respect the senior’s personal space and keep gestures slow and to a minimum.
  • Establish and maintain calm verbal contact.
  • Be concise and repeat what seems effective (e.g., suggest calming thoughts, memories, visuals, etc.).
  • When effective communication begins, identify and listen actively without interrupting.
  • Identify options for the senior to choose from (e.g., offer to lend a hand or to provide a distraction like turning on the TV, etc.).

Applying Problem Adaptation Therapy

Incorporating PATH into your senior loved one’s routine can change the way they feel about life. PATH techniques can empower them to take charge of their personal space and find the emotional skills they need to see life positively.

A good way to start is to identify your loved one’s triggers through conversation and careful note-taking. During discussions, try to learn which settings and situations trouble them. For instance, maybe the place they keep their keys, mail, and other important items is too disorganized. Maybe the kitchen is overfilled with storage containers, tools, and utensils they no longer use. Maybe their bathroom is cluttered with over-the-counter remedies that make it hard to find their essential medications.

Interviewing your loved one puts them in charge of identifying their frustrations. From these interviews, you and your loved one can set about making changes that make their life easier. Once changes are made, observe your loved one for a week or two to see if they’re better able to navigate themselves without becoming upset. You may need to conduct more than one round of interviews to address all problem areas.

Keep the five stages in mind, and employ whichever you feel applies to the situation. For example, if your loved one tends to become disoriented and doesn’t want to be alone while you cook dinner, attentional deployment may help. If there’s room in the kitchen, set them up a tablet where they can watch their favorite TV show while remaining close to you. You could also have them work on a fun activity you’ve prepared ahead of time. More simple techniques, like turning on calming music, may also help your loved one relax.

Even as you and your loved one work to streamline the home, emotions may still run high from time to time. Your loved one may suffer from sundown syndrome, which may make it difficult to cope no matter how much they work on taking charge of their spaces and feelings.

Remember that what you learn through interviews and practicing attentional deployment is very important. Your observations can provide useful information to a therapist or another memory-focused professional if you ever need outside support.

When you need help applying Problem Adaptation Therapy

If you are caring for your loved one at home and need help deciding how to use PATH, a licensed therapist may provide the support and guidance you need. Skilled therapists can coach patients and caregivers through emotionally tense situations with a variety of dementia treatment options, including PATH techniques.

Talk with a Senior Living Advisor

Our advisors help 300,000 families each year find the right senior care for their loved ones.

If you need professional support

If your loved one’s needs become more than you can manage alone and caregiver stress becomes an issue, perhaps in-home care, adult daycare, or even a move to a memory care community is in order.

If you want your loved one to receive PATH-like support, either with an in-home care service or at a memory care community, consider the following questions to ask any prospective caregivers:

  • Do you interview your memory care patients to understand their fears, wants, and personal histories?
  • How adaptable are the environments where your residents spend their time?
  • What specific environmental modifications do you allow so that your patients have what they need to succeed?
  • Does the layout of your community support the memory care work you do? If so, how?
  • How do you specifically engage, calm, or distract your patients that have become agitated?
  • How would you describe the tone of your patient interventions?
  • What specifically do you do for residents expressing a depressed mental state?

Next steps

The best memory care-focused caregivers are in touch with the latest in Alzheimer’s and dementia research, so seek out providers and communities that are familiar with therapies PATH.

Flexibility and accessibility are two key advantages of PATH. If a senior living community doesn’t have a PATH-certified professional on staff, make sure they’re applying PATH-like, person-centered memory care techniques and demonstrating a flexible approach to treating the specialized needs of seniors with dementia or other memory-related conditions.

If you would like help in your search for a specialized in-home care provider or memory care community, Senior Living Advisors at A Place for Mom offer free help and can connect you with the right solution.

To get involved with Dr. Kiosses and his team at the Emotion, Cognition, and Psychotherapy Lab at Weill Cornell Medicine, or to learn more about ongoing research studies on PATH and other topics underway there, visit their website for open clinical trials.

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A Place for Mom editor Marlena Gates and content strategist Jess Mathews contributed to this article.

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Sources:

The American Journal of Geriatric Psychiatry.“Adapting and Optimizing Problem Adaptation Therapy (PATH) for People With Mild-Moderate Dementia and Depression.”

The American Journal of Geriatric Psychiatry. “Home-delivered problem adaptation therapy (PATH) for depressed, cognitively impaired, disabled elders: A preliminary study.”

The Carlat Report: Psychiatry. “The 10 Commandments of Verbal De-Escalation.”

Interview conducted with Kiosses D. September 13, 2021.

Gross, James J., editor. Handbook of Emotion Regulation.

Jama Psychiatry. “Problem Adaptation Therapy (PATH) for Older Adults with Major Depression and Cognitive Impairment: A Randomized Clinical Trial.”

Journal of the International Neuropsychological Society.“Cognitive Functioning and Late-Life Depression.”

The New York Times.“New Therapies Help Patients with Dementia Cope with Depression.”

Author
Haines Eason

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