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. 2023 Apr 17;64(4):gnad046. doi: 10.1093/geront/gnad046

Behavioral Activation: Values-Aligned Activity Engagement as a Transdiagnostic Intervention for Common Geriatric Conditions

Meaghan A Kennedy 1,2,#,✉, Courtney J Stevens 3,4,#, Renée Pepin 5, Kathleen D Lyons 6,7
Editor: Joseph E Gaugler
PMCID: PMC10943502  PMID: 37068017

Abstract

Scalable, transdiagnostic interventions are needed to meet the needs of a growing population of older adults experiencing multimorbidity and functional decline. Behavioral activation (BA) is a pragmatic, empirically supported treatment for depression that focuses on increasing engagement in values-aligned activities. We propose BA is an ideal transdiagnostic intervention approach for older adults because it (a) specifically targets activity restriction, a shared characteristic of common conditions of aging; and (b) has strong potential for scalability through delivery by a broad range of clinician and nonclinician interventionists and via telehealth. We describe the history of BA and review recent literature demonstrating impacts beyond depression including on cognition, social isolation, and disability. We also describe the feasibility of delivering BA across interventionists, settings, and modalities. Our approach advances scholarship by proposing BA as a scalable, transdiagnostic behavioral intervention to address functional decline in older adults with common geriatric conditions.

Keywords: Behavioral interventions, Disability, Functional limitations, Multimorbidity

Functional decline—the development of limitations in independently carrying out daily activities—has a multifactorial etiology in older adults, but is often preceded by the onset of common geriatric conditions, such as cognitive decline, mobility limitations, depression, and multimorbidity (Kritchevsky et al., 2019; Stuck et al., 1999). A unifying characteristic of these geriatric conditions is activity restriction, or decreased engagement in daily activities (Oh et al., 2021; Yang & Kim, 2022). Activity restriction is often compounded by fewer readily available opportunities to engage in values-aligned activities due to changes in life context and loss of social roles in aging, such as retirement from the workforce (Irving et al., 2017; McKenna et al., 2007). According to behavior theory, when the environment does not provide sufficient opportunities for positive reinforcement (e.g., experiences of pleasure, mastery, or meaning vis-a-vis daily activities), activity restriction will increase (Hill et al., 2017).

Behavioral activation (BA) is an empirically supported psychotherapy for depression based in behavior theory (Cuijpers et al., 2007; Dimidjian et al., 2011; Jacobson et al., 2001; Kanter et al., 2010). BA aims to reduce activity restriction by helping clients identify, schedule, and perform important activities, thereby increasing opportunities for positive reinforcement (Lejuez et al., 2011; Martell et al., 2022). Numerous studies have shown BA is efficacious across populations (age, culture, race/ethnicity), delivery modalities (in-person, web-based, telemedicine), clinical settings (primary care, community programs, long-term care), and intervention intensity (number of sessions, duration) (Cuijpers et al., 2007; Dimidjian et al., 2011; Kanter et al., 2010; Orgeta et al., 2017).

We propose BA is a promising transdiagnostic approach for targeting activity restriction and increasing functional independence among older adults. Prior work suggests BA is highly effective for treating late-life depression (Alexopoulos et al., 2016; Orgeta et al., 2017; Polenick & Flora, 2013) and there is mounting evidence in support of using BA to address activity restriction and associated sequelae among non-depressed older adults (Brick et al., 2020; Bruce et al., 2021; Choi, Pepin, et al., 2020; Lyons et al., 2019; Rovner et al., 2018). Herein, we provide an introduction to BA and its roots as a treatment for depression, describe why BA is well suited to geriatrics, review the evidence in support of BA interventions targeting common geriatric conditions, and describe the potential to scale up applications of BA to meet the needs of an aging population, despite access barriers and limited resources.

BA as a Treatment for Depression

BA was conceptualized as a treatment for depression by behaviorists such as Drs. Charles Ferster and Peter Lewinsohn who were proposing non-psychoanalytic explanations for depression (Ferster, 1973, 1974; Lewinsohn, 1974) prior to the publication of Dr. Beck’s cognitive theory of depression (Beck et al., 1979). In the modern psychotherapy landscape, BA is an appealing treatment approach because it is relatively brief, typically involving between 6 and 24 individual sessions. Although BA treatment protocols vary (Lejuez et al., 2011; Martell et al., 2022), the core features include psychoeducation, activity monitoring, activity scheduling, skills training, and contingency management (Kanter et al., 2010).

The BA model of depression is rooted in behavior theory and principles of operant conditioning (Ferster, 1973; Lewinsohn, 1974). The central assumption is that lack of response-contingent positive reinforcement results in a feedback loop of activity restriction and worsening mood known as the “downward-spiral” of depression (Carvalho & Hopko, 2011; Jacobson et al., 2001; MacPhillamy & Lewinsohn, 1974; Martell et al., 2022). The term response-contingent positive reinforcement describes rewards experienced as a direct result of behavior that increase the likelihood the behavior is repeated (Hill et al., 2017). Rewards can be extrinsic, such as payment for a completed job, or intrinsic, such as the experience of pleasure, pride, mastery, and the sense that one is acting in alignment with their values and identity. With increasing activity restriction, there are fewer opportunities for the environment to provide positive reinforcement (MacPhillamy & Lewinsohn, 1974); the absence of pleasure, pride, mastery, and/or meaning as part of daily life worsens mood which likewise increases activity restriction (Carvalho & Hopko, 2011; Hill et al., 2017). In BA, treatment seeks to foster upward spirals of positive mood by increasing engagement in activities aligned with clients’ goals and values such that opportunities for positive reinforcement are increased.

Applying BA to Activity Restriction in Common Geriatric Conditions

Activity restriction in key life domains (e.g., physical, cognitive, and social) that affect functioning is shared by many physical and mental health conditions of aging, including depression, cognitive decline, mobility loss, and multimorbidity (Beauchamp et al., 2016; Choi, Bruce, et al., 2020; Marengoni et al., 2011; Oh et al., 2021). Oh et al. (2021) found older adults with functional limitations were less likely to engage in meaningful activities (i.e., physical, cognitive, or social) than those without limitations. Aging is also characterized by changes in roles, relationships, and living situations that may alter or limit the ability to participate in valued activities (Heckhausen et al., 2021; Irving et al., 2017).

Activity restriction can occur for many reasons. Sometimes a person’s life context changes in such a way that there are new barriers to participation, such as an injury that requires someone to modify their approach to a favored activity. Sometimes people have a hard time identifying modifications that would allow them to continue performing favorite activities and sometimes unpleasant emotions outweigh desire to participate all together, resulting in behavioral avoidance. Behavioral avoidance is maintained via negative reinforcement—the removal of something unpleasant or aversive that increases the likelihood the behavior is repeated (Ferster, 1973; Kanter et al., 2011). For example, canceling plans may temporarily alleviate unpleasant feelings associated with the effort of doing an activity that has become hard to do in older age.

Akin to the behavioral model of depression in older adulthood (Fiske et al., 2009), we suggest that behavioral avoidance, a form of activity restriction, is a transdiagnostic characteristic shared by many of the common geriatric conditions. For example, cognitive impairment may result in avoidance of cognitively demanding tasks that were once enjoyable, such as solving crossword puzzles or attending social events. Similarly, experiencing pain from arthritis may result in avoidance of certain physical activities such as walking or gardening. In turn, this reduction in activity engagement contributes to functional decline over time (Gill et al., 2003). Our conceptual model views activity restriction as a mediating factor between common geriatric conditions and functional decline (Figure 1). BA disrupts this cyclical process through activity restriction by increasing engagement in values-aligned activities. Our conceptual model is supported by research demonstrating the mediating effect of activity engagement on the relationship between depression and physical functioning (Bamonti & Fiske, 2021) as well as the positive impact of BA interventions for older adults on both activity engagement (Orgeta et al., 2019; Raue et al., 2022; Rovner et al., 2018) and functional outcomes (Bruce et al., 2021; Choi, Marti, et al., 2020; Choi, Pepin, et al., 2020; Orgeta et al., 2019; Rovner et al., 2018).

Figure 1.

Figure 1.

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Conceptual model. Activity restriction may mediate the relationship between common geriatric conditions and functional decline, with an individual’s psychosocial, socioeconomic, and environmental context impacting these relationships at all levels. Behavioral activation disrupts this cycle by reducing activity restriction through increasing engagement in values-aligned activity.

Our conceptual model acknowledges bidirectional relationships between common geriatric conditions, activity restriction, and functional decline (Figure 1). The model also acknowledges these relationships are influenced by the context in which older adults live: the psychosocial, socioeconomic, and environmental factors that shape their day-to-day lives. By focusing on engagement in values-aligned activities across different life domains (e.g., physical, cognitive, and social), BA interventions have the potential to broadly affect outcomes for specific physical and mental health conditions and functioning overall. The BA model also addresses contextual factors; for example, BA can be tailored to address social isolation (Pepin et al., 2021). Through activity scheduling in BA, the environment is modified such that it provides more opportunities for response-contingent positive reinforcement—for example, engaging aging services to discuss financial or transportation resources. Additionally, a BA interventionist can work with the client to modify activities that have become less rewarding to address or prevent avoidance of important activities and routines (Stevens et al., 2020).

Values-aligned activity scheduling is a critical component of a commonly used, evidence-based BA protocol (Lejuez et al., 2011). In this model, exploration of values is completed prior to selecting activities or goal-setting to ensure selected goal activities are in line with values, thus strengthening the positive reinforcement of activity engagement (Lejuez et al., 2011). Therefore, BA interventions offer a structured and personalized approach to increasing engagement in values-aligned activities (Pepin et al., 2021). Exploration of values or “What matters most” is an area of critical importance for geriatrics and lies at the center of key geriatrics care models including the American Geriatrics Society’s 5M’s and Age-Friendly Health Systems (Fulmer et al., 2018; Tinetti et al., 2017).

In Figure 2, we provide a clinical example of an older adult experiencing multiple common geriatric conditions and demonstrate how BA disrupts the downward spiral via increased engagement in values-aligned activities. Consider Ms. N, a hypothetical 80-year-old female experiencing multimorbidity (e.g., arthritis, diabetes, and congestive heart failure) and social isolation, recently exacerbated after she lost her ability to drive. An interventionist delivering values-based BA might help Ms. N identify that what matters most to her is spending time with her grandchildren. However, recently, she has not been seeing them very often because she has been more fatigued and has had more arthritis pain. She feels frustrated she cannot easily leave the house to run errands or go to the park where she likes to see her grandchildren. Instead, she has been spending more time sleeping and watching television, which has contributed to worsened mood and mobility. To get Ms. N started on an upward spiral, the interventionist might help her to problem solve barriers to her goal of spending more time with her grandchildren and use “graded tasks” (Martell et al., 2022) to define small achievable goals for her to complete for homework (e.g., call her daughter or a friend to ask for a ride to the park). In this example, even small actions (Step 1: Call daughter) have the potential to be positively reinforcing because they are performed in the service of Ms. N’s values and, when accomplished, increase her sense of mastery. Over time, as Ms. N increases time spent engaged in values-aligned physical and social activities, our model predicts her overall mood and physical functioning would improve.

Figure 2.

Figure 2.

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Clinical example. Core behavioral activation intervention techniques including psychoeducation, activity monitoring, values-aligned activity scheduling, graded tasks, and problem solving are used to target activity restriction via increased engagement in values-aligned activities, thereby disrupting the downward spiral between common geriatric conditions and functional decline.

Innovative Applications of Behavioral Activation in Older Adults

Expanding the Model of BA Beyond Depression

A growing body of research demonstrates the potential for BA as an intervention approach for conditions other than depression in older adults. Here, we review applications for BA in older adults experiencing cognitive impairment, social isolation, pain, and functional limitations. As described previously, a unifying feature of these and other common geriatric conditions is activity restriction, which is a direct target of BA.

Cognitive impairment

Several recent protocols have used BA for older populations experiencing cognitive impairment. Rovner et al. (2018) conducted a randomized controlled trial of BA delivered by community health workers (CHWs) in Black older adults with mild cognitive impairment (MCI). CHWs delivered five BA sessions for 4 months followed by six maintenance sessions for the next 20 months, compared with a supportive therapy control arm. The BA protocol incorporated specific elements to address cognitive impairment in action plans, such as visual cues and step-by-step sequencing. Intervention participants showed stable cognitive function versus a decline in the comparison group and reported increased cognitive activity engagement (Rovner et al., 2018). Orgeta et al. (2019) similarly investigated BA for mild dementia in a pilot RCT, demonstrating improvement in functioning in activities of daily living and increased engagement in meaningful and enjoyable activities among participants receiving an 8-weekly-session BA protocol compared with usual care (Orgeta et al., 2019). Activity engagement can improve well-being in people living with dementia and several intervention protocols have focused on this approach (Gitlin et al., 2021; Möhler et al., 2020; Regier et al., 2022). Orgeta et al. (2019) and Rovner et al.’s (2018) work demonstrating the capacity of BA to improve meaningful activity engagement in individuals with cognitive impairment suggests that BA may be an effective engagement strategy in this population.

Social isolation

Social isolation, which is highly prevalent and associated with adverse outcomes among older adults (Steptoe et al., 2013), may be sensitive to BA’s ability to increase engagement in social activities. Choi et al. (2020) recently examined the impact of BA delivered by lay counselors in socially isolated older adults without depression. BA was delivered via videoconferencing for five sessions compared with a friendly visitor attention control. The authors found that the tele-BA group had greater decrease in social isolation, depressive symptoms, and self-reported disability at 12 weeks (Choi, Pepin, et al., 2020) and that benefits were maintained at 12-month follow-up (Bruce et al., 2021).

Pain

Given the co-occurrence and bidirectional relationships between depression, pain, and mobility in older adults, BA may be well suited to interventions focused on pain management and rehabilitation. Brooks et al. (2021) conducted a small pilot study of BA delivered in a co-facilitated group setting by older peers and a clinician to older adults with co-occurring chronic pain and mental health diagnoses (Brooks et al., 2021). This 6-week group program consisted of core BA content with additional psychoeducational material focused on pain management. Preliminary findings from eight participants showed improvements in risk of opioid misuse and trends toward reduction in pain and depression symptoms.

Functional limitations

BA has potential as a rehabilitative approach in older adults experiencing functional limitations. Lyons et al. (2019) conducted a pilot RCT examining BA delivered by occupational therapists (OTs) to older adults with cancer experiencing activity limitations. The “Heath through Activity” program consisted of 6 weekly in-home sessions focused on activity scheduling, problem solving, and OT support through education, environmental changes, or acquiring adaptive equipment. Findings demonstrated feasibility of implementation, and there were non-significant trends toward improvement in self-reported disability and quality of life for 4 months of follow-up (Lyons et al., 2019). In a recent review, Brick et al. (2020) outlined the potential role of BA as an adjunct therapy in OT settings as a means of helping individuals maintain engagement in skills and activities outside of the formal rehabilitation setting. Further supporting this application, studies in older adults both with and without depression have shown improvements in measures of functioning and disability (Bruce et al., 2021; Choi, Marti, et al., 2020; Choi, Pepin, et al., 2020; Rovner et al., 2018).

Flexibility Across Interventionists, Settings, and Modalities

The proportion of the health care workforce with geriatrics specialty training is insufficient to meet the needs of the ever-growing population of adults older than age 65 (U.S. Department of Health and Human Services, 2017). BA may be an ideal intervention approach when the goal is to increase access to health and mental health services for older adults because it is both pragmatic and scalable. Specifically, (a) BA is a manualized intervention delivered for a limited number of sessions, (b) BA can be delivered by interventionists without specialized mental health backgrounds, and (c) BA protocols have demonstrated feasibility in diverse settings and via remote modalities, which may increase accessibility for older adults who are homebound or geographically isolated (Choi, Marti, et al., 2020; Dimidjian et al., 2011; Gilbody et al., 2017).

Nonclinician interventionists

A particularly appealing feature of BA as a brief, manualized psychosocial intervention is the capacity for scalability through delivery by nonclinician interventionists or lay counselors (Choi, Marti, et al., 2020; Choi, Pepin, et al., 2020; Raue et al., 2022; Rovner et al., 2018). BA is simpler to administer and train others to administer compared with other evidence-based transdiagnostic interventions/psychotherapies, such as cognitive–behavioral therapy (Richards et al., 2016) and problem solving therapy (PST) (Alexopoulos et al., 2015). A recent RCT (Choi, Marti, et al., 2020) examined the comparative effectiveness of video telehealth-BA delivered by bachelors-level counselors compared with clinician-delivered tele-PST and an attention control (supportive phone calls) for homebound older adults with depression. Participants received five weekly sessions followed by monthly booster calls. Older adults who received tele-BA or tele-PST had higher depression remission rates than those in the attention control group at 9 months. Tele-PST was more effective at reducing depressive symptoms than tele-BA, but the two groups had similar improvements in self-reported disability, social engagement and activities, and social role satisfaction. Participants found the format of BA understandable and helpful, noting benefits of activity planning, positive effects of increased activity, and improved mood (Choi et al., 2021).

Utilizing supervised senior center volunteers as interventionists, Raue et al. (2022) conducted a pilot RCT of a volunteer-led BA protocol (“Do More, Feel Better”) versus BA delivered by Masters-level social workers for senior center clients with depression. Findings demonstrated acceptability of the intervention among participants, feasibility of training volunteer interventionists to fidelity, and clinically significant improvements in activity level and depressive symptoms in both groups. Evaluation of acceptability through survey of senior center clients and volunteers showed that 81% would consider participating in a volunteer-led BA program and 59% would be interested in serving as intervention coaches (Raue et al., 2021). The potential to scale up BA interventions using lay interventionists further supports our central proposal that BA is an ideal transdiagnostic approach to meet the needs of a growing population of older adults experiencing multimorbidity and functional decline.

Diverse clinical and community settings

Several studies demonstrate transferability of BA across different clinical settings, including primary care (Cuijpers et al., 2019; Gilbody et al., 2017), home-based care (Choi, Marti, et al., 2020; Choi, Pepin, et al., 2020), and long-term care (Meeks et al., 2015) via both in-person and telehealth modalities. Implementation in primary care settings may be particularly beneficial for older adults with subclinical or mild depressive symptoms, MCI, or multiple chronic conditions associated with functional decline that are commonly identified by primary care clinicians.

Innovative BA implementation models in collaboration with community aging agencies (Choi, Marti, et al., 2020; Choi, Pepin, et al., 2020; Quijano et al., 2007; Raue et al., 2022) may improve access for older adults who may be otherwise hard to reach due to mobility limitations or social or geographic isolation. Such collaborative efforts may also support engagement from older adults who are accustomed to receiving services and recommendations from these agencies. Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) was developed as a community-based BA intervention delivered by case managers for older adults with depressive symptoms receiving services from community aging agencies (Quijano et al., 2007). Case managers conducted screening and assessments, made referrals to services, and provided education for a 6-month intervention period. Pre–post analyses demonstrated a reduction in depression symptoms as well as improvement in self-management and self-reported pain. Implementation factors have been studied (Casado et al., 2008) and the program has now been broadly disseminated, with recognition as an evidence-based program for depression in older adults by the CDC (Centers for Disease Control and Prevention and National Association of Chronic Disease Directors, 2009).

BA has also been used in long-term care settings to treat depression through a collaborative care model. In BE-ACTIV, nursing home residents with depression received 10 weeks of BA delivered by a mental health therapist with a nursing home staff member serving as a facilitator to help the residents engage in selected pleasant activities between sessions (Meeks et al., 2008, 2015). In an RCT of 82 nursing home residents receiving BE-ACTIV versus usual care, those in the intervention arm were more likely to achieve clinical recovery from depression at follow-up. Both groups had improvements in self-reported depressive symptoms and functioning which were not significantly different (Meeks et al., 2015).

Conclusion

In this forum article, we have provided the theoretical rationale for our conceptual model and reviewed evidence supporting BA as a scalable approach to address common geriatric conditions, not limited to depression, across a diverse range of health care delivery contexts and settings. The focus of BA on increasing values-aligned activity engagement across life domains is particularly well suited to older adults, who commonly experience activity restriction as a result of chronic health conditions and contextual life changes. Evidence supports broad applications for BA in older adults, with studies showing impacts for those experiencing social isolation, functional decline, pain, and cognitive impairment. This potential as a transdiagnostic intervention is essential given the frequent co-occurrence of common chronic conditions experienced by older adults, with shared sequelae of functional decline and disability.

Our perspective has potential to move scholarship forward by emphasizing a behavioral approach to reducing multimorbidity and functional decline with broad transdiagnostic application in older adults experiencing common geriatric conditions. Future research is needed to empirically test the proposed relationships in our conceptual model between BA, activity engagement, and functioning outcomes across domains (physical, cognitive, mental, and social). Furthermore, rigorously designed studies are needed to establish optimal strategies for BA interventionist training and supervision, particularly for nonclinicians such as CHWs and aging services workers who may help expand BA’s reach to more isolated populations. Finally, studies should test strategies for implementation across the continuum of care for older adults, including group-based and dyadic BA interventions as well as best practices for remote modalities.

Acknowledgments

The authors thank Kathleen Mitchell, MPH, for their contributions to the figures.

Contributor Information

Meaghan A Kennedy, New England Geriatric Research, Education, and Clinical Center, VA Bedford Healthcare System, Bedford, Massachusetts, USA; Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.

Courtney J Stevens, Department of Psychiatry, Dartmouth-Hitchcock Medicine Center, Lebanon, New Hampshire, USA; Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.

Renée Pepin, Department of Community and Family Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.

Kathleen D Lyons, Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA; Department of Occupational Therapy, MGH Institute of Health Professions, Boston, Massachusetts, USA.

Funding

This work was supported by the National Cancer Institute, National Institutes of Health (K08CA259632 to C. J. Stevens and R01CA225792 to K. D. Lyons) and by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Rehabilitation Research and Development Service (IK2RX003930 to M. A. Kennedy). The contents do not represent the views of the U.S. Department of Veterans Affairs, the National Institutes of Health, or the United States Government.

Conflict of Interest

None declared.

Data Availability

The authors do not report on original data in this manuscript and therefore pre-registration and data availability requirements are not applicable.

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