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Depression and dementia in old age: improving effective care and prevention

Published online by Cambridge University Press:  21 March 2019

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Abstract

Type
From the Editor's Desk
Copyright
Copyright © The Royal College of Psychiatrists 2019 

A growing aged population presents challenges for healthcare professionals in terms of ensuring the right capacity and skills are enshrined in training programmes, and that health services and social care be organised and delivered in an age-appropriate manner commensurate with need.Reference Cheung, Bailey, Subau and Martínez-Ruiz1 The coexistence of mental and physical illnesses, often with shared aetiologies or mutually reinforcing pathophysiology, recommends better models of care that integrate old age psychiatry, general medicine and neurology training schemes and services.Reference Fisher and Teodorczuk2

Depression in older age is associated with a higher mortality, irrespective of country context.Reference Brandao, Fontenelle, da Silva, Menezes and Pastor-Valero3 Briggs et al (pp. 230–236) suggest that lower frontal lobe blood perfusion because of low blood pressure is associated with depression in community resident older people. Fancourt & Tymoszuk (pp. 225–229) approach the conundrum from quite a different perspective; they find that cultural engagement, visiting museums for example, appears to protect against depressive symptoms. Late-life depression shows high rates of non-response to treatment. Sahaj Samadhi meditation was expected to improve heart rate variability, a marker of cardiovascular health in late-life depression, in a trial run by Ionson et al (pp. 218–224). They found that it had no effect on heart rate variability, but there was a reduction in depressive symptoms over time. Depression is also a risk factor for self-harm and suicide, but this is less researched in older populations who also have other risk factors such as chronic pain and medical disabilities. Troya et al (pp. 186–200) plead that we make use of the frequent contact with health services to assess for self-harm, and that community-based models of research and prevention are also needed.

Population preventive models aim to stem the growing numbers of older people living with dementia. The relationship between early depressive and emotional symptoms and later dementia is the subject of exciting but as yet equivocal implications for prevention.Reference Rubin4,Reference Ismail, Gatchel, Bateman, Barcelos-Ferreira, Chantillon and Jaeger5 Could population-based opportunities to improve depressive symptoms also help reduce both depression and dementia risk? For dementia, scientists still need a target stage, a coherent model that can be applied at a population level, and appropriate interventions that show promise.Reference Mar, Soto-Gordoa, Arrospide, Moreno-Izco and Martínez-Lage6,Reference Ganguli, Albanese, Seshadri, Bennett, Lyketsos and Kukull7 However, risk factors found at the level of populations, for example, polygenic risk scores, do not easily perform as screening criteria.Reference Wald and Old8 Depressive symptoms may be a useful marker for a critical period of intervention before the onset of more significant cognitive impairment. The use of drug-based prevention for dementia is also not currently supported by evidence.Reference Mar, Soto-Gordoa, Arrospide, Moreno-Izco and Martínez-Lage6,Reference Birdi, Stephan, Robinson and Davis9

Dementia care is put under the microscope by Dooley et al (pp. 213–217), who report that doctors, when offering diagnostic information to patients with cognitive impairment, most often make suggestions and assertions, and less often pronouncements and offers of intervention. Despite this range, 80% of patients did not clearly accept the advice, and were likely to resist suggestions. The level of cognitive impairment in patients did not influence the type of communication method chosen, and patient preferences did not influence recommendations for use of medication. Delirium is a common comorbidity found in dementia care, usually suggesting more severe illness and poor physical health and a higher mortality. Training staff to improve their knowledge of dementia and delirium does not improve patient outcomes, although staff knowledge appeared to improve a little (Abley et al, pp. 201–212)).

References

1Cheung, G, Bailey, A, Subau, D, Martínez-Ruiz, A. International perspectives on old age psychiatry training. Am J Geriatr Psychiatry 20 Dec 2018 (doi: 10.1016/j.jagp.2018.12.021).Google Scholar
2Fisher, J, Teodorczuk, A. Old age psychiatry and geriatric medicine: shared challenges, shared solutions? Br J Psychiatry 2017; 210: 91–3.Google Scholar
3Brandao, DJ, Fontenelle, LF, da Silva, SA, Menezes, PR, Pastor-Valero, M. Depression and excess mortality in the elderly living in low- and middle-income countries: systematic review and meta-analysis. Int J Geriatr Psychiatry 2019; 34: 2230.Google Scholar
4Rubin, R. Exploring the relationship between depression and dementia. JAMA 2018; 320: 961–2.Google Scholar
5Ismail, Z, Gatchel, J, Bateman, DR, Barcelos-Ferreira, R, Chantillon, M, Jaeger, J, et al. Affective and emotional dysregulation as pre-dementia risk markers: exploring the mild behavioral impairment symptoms of depression, anxiety, irritability, and euphoria. Int Psychogeriatr 2018; 30: 185–96.Google Scholar
6Mar, J, Soto-Gordoa, M, Arrospide, A, , Moreno-Izco, F, Martínez-Lage, P, et al. Fitting the epidemiology and neuropathology of the early stages of Alzheimer's disease to prevent dementia. Alzheimers Res Ther 2015; 7: 2.Google Scholar
7Ganguli, M, Albanese, E, Seshadri, S, Bennett, DA, Lyketsos, C, Kukull, WA, et al. Population neuroscience: dementia epidemiology serving precision medicine and population health. Alzheimer Dis Assoc Disord 2018; 32: 19.Google Scholar
8Wald, NJ, Old, R. The illusion of polygenic disease risk prediction. Genet Med 12 Jan 2019 (doi: 10.1038/s41436-018-0418-5).Google Scholar
9Birdi, R, Stephan, BC, Robinson, L, Davis, D. Can we influence the epidemiology of dementia? Perspectives from population-based studies. Postgrad Med J 2015; 91: 651–4.Google Scholar
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