Providentia

Fact or artefact? Childhood adversity and adulthood trauma in the U.S. population-based Health and Retirement Study.

Despite the well-known deleterious health effects of childhood adversity (CA) and adulthood trauma (AT) and ageing of the global population, little is known about self-reported CA and AT in older populations. Existing findings are mixed due to methodological and sampling artefacts, in particular, recall and selection biases, and due to age-period-cohort effects.  In a new study published in the European Journal of Psychotraumatology, researchers provide data on the prevalence of retrospective self-reported CA and AT in a large population-based sample of older adults and discuss the data in the context of major methodological and sampling artefacts, and age-period-cohort effects.  Data are derived from the U.S. population-based Health and Retirement Study (N = 19,547, mean age = 67.24 ± 11.33, 59% female). Seven birth-cohorts were included (< 1924, 1924–1930, 1931–1941, 1942–1947, 1948–1953, 1954–1959, >1959). Results: showed that 35% of participants reported CA and 62 *% AT, with strong variability among birth-cohorts. Opposing trends were observed regarding prevalence of CA and AT. As age of cohorts increased, prevalence of CAs decreased while that of ATs increased. Investigating the distributions of incidence of specific ATs across age and period per cohort revealed incidence of exposure was associated with (1) age (e.g. having lost a child), (2) time-period (e.g. major disaster), and (3) cohort (e.g. military combat).  In conclusion, retrospective self-reported CA and AT in older samples should be interpreted with caution and with regard to major methodological challenges, including recall and selection biases. Untangling fact from artefact and examining age, period, and cohort effects will help elucidate profiles of lifetime exposures in older populations.

For the abstract (Open access)

Prisons Warn of "Silver Tsunami" of Prisoners with Dementia in Coming Years

Much like the rest of society, there are more elderly prisoners behind bars than ever before.  And it's a trend that will only worsen in the future.

According to the U.S. Census Bureau, the number of people over the age of 55 will likely double over the next ten years.  That will mean more than 400,000 older prisoners accounting for almost one in every three incarcerated people, many of whom will have serious health problems that can only become worse given prison conditions.   Due to the "tough on crime" policies of the past three decades, including "three-strikes" laws and mandatory sentencing, the United States currently houses 22 percent of the world's prisoners (despite accounting for only 4.4 percent of the world's total population).   The costs of operating federal and state prisons, jails, and parole/probation offices currently costs about $72 billion dollars a year and, as the costs of caring for elderly prisoners also continue to rise, likely far more in future.  

Along with all the other age-related medical problems that cost the Federal Bureau of Prisons an estimated $881 million dollars, the rising number of elderly prisoners suffering from dementia has become the focus of a legal and ethical battle that seems unlikely to end.    In 2019, the first Federal unit dedicated to caring for prisoners with dementia opened with trained staff, including nurses, to provide specialized care as needed.  Still, with the number of prisoners with dementia expected to rise as high as 211,000 by the end of the decade, prisons will need to do far more to provide the round-the-clock care many of them will need.

One of the legal concerns in keeping prisoners with dementia behind bars is the Eight Amendment of the U.S. Constitution banning cruel and unusual punishment.  Which means that prisons may not be able to justify holding prisoners who are no longer able to understand why they have been incarcerated and who are unable to cope with daily life inside.   A February 2019 case has already determined hat it is unconstitutional to execute someone who cannot rationally understand their death sentence because it serves has no retributive purpose.   That particular case centered around a prisoner who developed severe dementia after a series of strokes but more legal challenges are expected concerning the legality of indefinitely detaining prisoners with dementia.   

Prisoners with dementia are also at increased risk of being victimized by other prisoners, many of whom will them as easy targets who are vulnerable to bullying and intimidation.    Along with the frequent threat of violence, affected prisoners will also be unable to understand why they are in prison at all and why they are unable to get visits from family members and friends.  All of which may lead to their acting out in ways that will subject them to solitary confinement and other punishments that will make their dementia symptoms much worse.  

When I was working in the prison system as a psychologist, I dealt with numerous elderly inmates who showed many of the classic signs of dementia though they were never formally diagnosed due to their incarceration.  For the most part, they were frail, confused old men who needed to be kept in solitary confinement for their own protection given how vulnerable they were to being attacked or bullied by other inmates taking advantage of their mental confusion.   That this problem remains unresolved twenty years later, and will likely become far worse in prisons across the United States and Canada in the years to come, represents a critical challenge that needs to be addressed.    The alternative seems far too gruesome to contemplate.

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Does Bilingualism Slow Cognitive Aging?

Research has suggested that using two or more languages on a daily basis helps older adults maintain a heightened functional state and improves neurocomputational efficiency. In a new review published in the Journal of Neurolinguistics, researchers discuss studies that have examined the effect of life-long bilingualism on age-related cognitive and neural decline, with a focus on discrepancies between different sources of evidence. The review outlines and characterizes factors which might explain inconsistencies between studies claiming that bilingualism has neurocognitive benefits and those that failed to find such evidence. The authors argue that individual variation in language proficiency and exposure, especially language switching frequency and daily frequency of use of the two languages, likely account for a significant chunk of the inconsistencies found in the literature and constrain the effectiveness of bilingualism as a cognitive and brain reserve factor. Finally, the reviews discusses studies of cognitive intervention and speculate on the potential of developing language training protocols to increase cognitive and neural resilience in older adults.

For the abstract

Exploding the Myths About Aging

We don't stop playing because we grow old, we grow old because we stop playing - George Bernard Shaw

For all that we are regularly besieged with slogans such as "60 is the new 40",  many people continue to view growing older with a sense of dread.  Despite decades of research into human aging, not to mention the fact that people are living longer and more productive lives, there still seems to be a popular belief that older adults have nothing to look forward to but worsening health problems and becoming a burden on society.

A new opinion piece published in the journal American Psychologist explores some of the common misconceptions about aging that help reinforce this pessimism about growing older.  As Manfred Diehl of Colorado State University, Michael A. Smyer of Bucknell University, and Chandra M. Mehrotra of the College of St. Scholastica point out in their article, not only has life expectancy risen steadily in the United States over the past 100 years, but advances in medicine have ensured that those extra years remain disability-free for most people.  In fact, never before in human history have adults had so many years of active life available to them, something that gerontologists refer to as the "longevity dividend" 

To read more, check out my new Psychology Today blog post.

 

Should Dementia Be Grounds for Euthanasia?

In a decision by the Netherlands Supreme Court that was passed last week, it is now lawful for doctors to euthanize patients with severe dementia, provided that the patient had previously chosen to be euthanized while still legally capable of  making that decision. 

Since the passage of one of the first assisted dying laws in 2001, the Netherlands has remained at the forefront of the euthanasia debate with an estimated 6,000 euthanasia cases as of 2016 (amounting to four percent of all deaths in the country).   Under this legislation, a candidate for euthanasia much be at least twelve years of age and with suffering that is "unbearable with no prospect of improvement."  and the euthanasia decision is independently reviewed by a second physician.    Patients between the age of twelve and sixteen are also allowed to request euthanasia with parental permission.  The decision to receive physician-assisted suicide must also be completely voluntary and with full awareness of the legal and ethical issues involved.   

Most instances of euthanasia involve the drinking a a barbiturate  compound which needs to be taken by the patient with the doctor present to avoid possible misuse or coercion.  While the majority of euthanasia cases have involved patients with incurable cancer or other serious medical ailments,   there have been an increasing number of cases of psychiatric patients being granted permission as well, something that has provoked strong controversy nationally and internationally.

The debate over dementia and euthanasia has escalated since 2018 with the resignation of medical ethicist Berna van Baarsen from a regional euthanasia board over that very question.  In one media interview, van Baarsen stressed that she was no longer capable of defending the right of dementia patients to give advance directives.  “It is fundamentally impossible to establish that the patient is suffering unbearably, because he can no longer explain it,'" she said.   

In the recent decision concerning dementia patients, people with dementia are deemed qualified for euthanasia, but only if an advance directive had been made or discussed with a doctor previously.  “For some people, the prospect of ever suffering from dementia may be sufficient reason to make an advance directive (living will). This can either be drawn up independently or discussed first with the family doctor. A physician can perform euthanasia on a patient with dementia only if such a directive exists, if statutory care is taken and if, in his opinion, the patient is experiencing unbearable suffering with no prospect of improvement,” says the Dutch government’s website.

The case that was heard by the Netherlands Supreme Court involved an unnamed female doctor who was accused of having broken the law by facilitating the death of a 74-year-old woman four years earlier.  The woman at the centre of the case had written an advanced directive years earlier, requesting the procedure in lieu of being put in a nursing home. In the directive, she had said she wished to “be able to decide while still in my senses and when I think the time is right.”  Despite the directive, prosecutors maintain that she gave "mixed signals" about proceeding, including attempting to fight off the doctor though she was no longer capable of speaking.   Though the doctor was deemed to be acting "with the best of intentions",  she was accused of acting without the patient's knowledge by slipping a sedative into her coffee.    A lethal drug was then administered and family members needed to hold the patient down as she struggled against the injection.

Though lower courts upheld the doctor's right to act, it was still sent to the Supreme Court due to concerns about possible misuse of the country's euthanasia law.   Critics have long argued that the Netherlands and other countries allowing euthanasia are on a "slippery slope" and that including conditions such as dementia and mental illness may lead to a redefining of the value of human life.   They also suggest that end-of-life decisions will be taken out of the hands of patients and given to medical doctors who may not act in the patient's best interest.    

 While cases of euthanasia for people suffering from severe dementia will remain rare for now, this may well change in the years to come due to the rising number of dementia cases expected over the next two decades, as well as the increasing number of jurisdictions approving assisted dying.   As it stands, the recent Supreme Court decision will likely influence similar cases worldwide for years to come.  

 

Can Personality Traits Protect Against Cognitive Decline in Seniors?

Cognitive complaints and engagement in cognitive activities are two consistent predictors of cognitive aging outcomes, including risk for nonnormative decline. Though research has considered predictors of complaints and engagement in general, little work has attended to the fact that these fluctuate at the daily level. A study recently published in the journal Psychology and Aging examined individual difference predictors of means and variability for engagement and complaints across 10 days in a sample of older adults (n = 136; Mage = 70.45 years). When comparing personality traits to indicators of cognitive performance, personality differences appeared better unique predictors for these measures of daily cognitive life. Specifically, even when accounting for demographics, measures of cognitive performance, and the other personality traits investigated, older adults higher on openness to experience reported fewer daily cognitive complaints and more engagement on average, as well as greater daily variability in engagement. In addition, higher neuroticism predicted greater variability in reports of cognitive complaints across days. Implications are discussed with respect to how these findings advance our understanding of cognitive complaints and engagement in daily life. (PsycINFO Database Record (c) 2020 APA, all rights reserved)

For the abstract

Primary and Secondary Caregivers in Dementia

Having 2 or more relatives involved in the informal care of people with dementia is frequent worldwide. There are, however, few comparisons of primary and secondary caregivers and even fewer of those who are caring for the same person. Our study aimed to contrast these 2 experiences of caregiving. In a recent issue of Psychology and Aging, researchers compared 2 related samples of 61 primary and 61 secondary family caregivers of the same persons with dementia in a nonrandomized cross-sectional study. Caregivers’ main outcome assessments were the Zarit Burden Interview (for subjective burden), the General Health Questionnaire (for psychological distress), and the Positive Aspects of Caregiving scale. We controlled for caregiver variables (e.g., demographics, caregiving arrangements, social support, sense of coherence) and the neuropsychiatric symptoms of dementia. Subjective burden was higher in primary than secondary caregivers (p = .013), but positive aspects of caregiving did not differ (p = .150). Psychological distress was high at clinically relevant levels in primary and secondary caregivers, without statistically significant differences between groups (p = .456). The findings demonstrate that notwithstanding the difficulties faced by primary caregivers, secondary caregivers may also experience clinically significant distress. Therefore, their needs for assistance and support should be addressed more systematically. These findings call for systemic family-focused interventions in dementia that address the support each person provides or might provide, as well as the psychological distress each person may feel. 

For the abstract

Predicting Dementia With a Smartwatch

As part of a broad-based project by Alzheimer's Research UK, a million British people over the age of 40 will begin wearing special smartwatches designed to help detect early signs of dementia.  Over the three years of the planned study, the prototype smartwatches will monitor over thirty potential indicators of dementia, including changes in speech, fine motor skills, memory, and sleep patterns.   Researchers are hoping to use the data collected in the study to identify early "fingerprints" that will allow them to predict people at risk for developing dementia later in life.   All participants have been recruited by the U.K. government's Accelerating Detection of Disease programme.

In a recent article in the Daily Telegraph, former British Prime Minister David Cameron, who is current president of Alzheimer's Research UK, described the new project as an example of how technology can be use to help dementia sufferers who are "slipping into a world of darkness".   "It has an achievable aim: to develop a gadget - a combination of a wearable device and smartphone app - to detect the earliest digital fingerprints of a disease," he wrote.  "‘This isn’t some Big Brother intervention. Just as we measure our cholesterol levels to tell us when we need a statin, we need to identify these fingerprints of diseases such as Alzheimer’s to see when we need a statin for the brain.... As prime minister, I was determined to prove this wasn’t an inevitable part of ageing but was being caused by diseases of the brain that can be tackled with research.  That’s why I put the issue on the global agenda, through summits such as the G8, and we doubled the research funding at home. And it’s why I made it my focus post-politics."

Carol Routledge, director of research at Alzheimer’s Research UK, stressed the importance of Early Detection of Neurodegenerative diseases (EDoN) technology in detecting diseases in the very early stages.  "Our research shows that 85% of UK adults would be willing to take a test that could tell them if they were in the early stages of a disease like Alzheimer’s, even before symptoms show," she said in a recent media interview.  "EDoN aims to harness the growing popularity of digital health technology and big data to revolutionise how we develop early tests for these diseases. Developing digital fingerprints that can be detected using phone apps or wearable technologies like smart watches would provide a low-cost approach to identifying those most at risk of disease,” says 

Dementia is already the leading cause of death in the U.K. and, in many cases, failure to make a proper diagnosis in the early stages can mean a significant delay in receiving treatment.  While there is, at present, no cure for more types of dementia, including Alzheimer's disease, early diagnosis and treatment can help slow down decline and allow people with dementia to remain functioning as long as possible. 

The initiative is a collaboration between Alzheimer’s Research UK and organisations including the Alan Turing Institute, University College London, and Newcastle, Exeter and Cambridge universities.   Partially sponsored by the Bill and Melinda Gates Foundation, the project hopes to secure at least £67 million in funding in the first six years and up to £100 million by 2030.

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Can Air Pollution Increase the Risk of Dementia?

Can proximity to major roads or highways, not to mention increased exposure to air pollution, make people more vulnerable to a wide range neurological disorders, including dementia?    A new research study released by the University of British Columbia suggests that it can.

The study, which was recently published in the journal Environmental Health, used data collected 678,000 adults between the ages of 45 and 84 who lived in Metro Vancouver from 1994 to 1998 and during a follow-up period from 1999 to 2003.   The adults in the sample were assessed in terms of individual exposures to road proximity, air pollution, noise, and greenness at each person’s residence using postal code data.   After collecting data during the follow-up period, including medical history, the study researchers determined that a disproportionately high percentage of adults living with fifty meters of a major road or highway had been diagnosed with Alzheimer's disease, non-Alzheimer's dementia, Parkinson's Disease, and Multiple Sclerosis.   Alternatively, results suggest that living near green spaces, such as public parks may help protect against these diseases, something that urban planners need to take into consideration for future development.

“For the first time, we have confirmed a link between air pollution and traffic proximity with a higher risk of dementia, Parkinson’s, Alzheimer’s and MS at the population level,” says lead researcher Weiran Yuchi in a recent interview.    “The good news is that green spaces appear to have some protective effects in reducing the risk of developing one or more of these disorders."   While Yushi stresses that more research is needed, these results do suggest that urban planning to increase the availability of green spaces in major cities 

Research has already demonstrated that living near major roadways can result in increased exposure to air pollutants, particularly diesel trucks which are a major source of a nitrogen dioxide, ultrafine particles, and black carbon soot)near roads.   Though pollution exposure help account for the increased link to serious illness, UBC professor Michael Brauer, who was the senior researcher for the study, suggests that there may be other reasons for the protective effect of green spaces.   

“For people who are exposed to a higher level of green space, they are more likely to be physically active and may also have more social interactions,”  said Brauer in a recent media interview.   “There may even be benefits from just the visual aspects of vegetation.”   

Neurological disorders such as dementia and Parkinson's disease, represent one of the leading causes of disability in most industrialized nations.   In the Canadian health care system alone, estimated costs were more than 10 billion dollars in 2012 and these numbers are already rising as more baby boomers develop debilitating symptoms.   With individuals over the age of 65 expected to account for one-fourth of the total population of Canada by 2035, identifying possible ways to reduce these health risks is more essential than ever.   Providing more green spaces and curbing pollution can yield important health dividends as well as helping older adults to remain functioning as long as possible.

Is Race a Factor in Quality of Dementia Care?

While dementia can occur in any family, a new study  recently published in the journal Clinical Epidemiology suggests that significant racial differences exist in terms of quality of care that dementia patients receive.   A team of researchers at University College London analysed data from 53,718 people across the UK who had a dementia diagnosis, and 1,648,889 people without dementia, drawing from The Health Improvement Network primary care database and collected between 2014 and 2016.   Based on their findings,  Asian people with dementia were 14% less likely than white patients to be prescribed anti-dementia drugs when they were potentially beneficial, and received them for an average of 15 fewer days per year.  Also, when compared to White groups, Asian and Black individuals with dementia were no more likely to be prescribed antipsychotic drugs, but those that had were prescribed them for 17 and 27 days/year more, respectively.   

Although anti-dementia drugs - cholinesterase inhibitors or memantine - are the only class of medication available for treating early symptoms of dementia such as memory or other cognitive declines,   other medications such as antipsychotics are often prescribed to treat some of the associated behavioural and psychological symptoms.   The use of antipsychotic drugs in dementia patients remains controversial in many cases given that they can be overused as a means of  "calming down" and making them more manageable.   Socioeconomic factors may also come into play in facilities with insufficient staffing or care provided.

In discussing the new study findings, lead researcher Patricia Cooper expressed concern over the racial disparities in dementia care and the overuse of antipsychotic medication.  "Rates of antipsychotic prescribing in all ethnic groups exceeded recommendations for treating the often very distressing behavioural and psychological symptoms of dementia, such as agitation or challenging behaviours, which are the most common reasons antipsychotic drugs are prescribed to people living with dementia," she said.  "While there has been a very sharp reduction in antipsychotic prescribing in the UK over the past 10 years, these figures suggest there is still work to do to ensure that people with dementia only receive potentially harmful antipsychotic drugs if there are no acceptable alternatives."

Co-author Dr Mary Elizabeth Jones (UCL Institute of Epidemiology & Health Care) has also weighed in on the dangers of overprescribing antipsychotic medication.  "While we have yet to find out whether taking antipsychotic drugs for a few weeks more increases the associated risks, which can include falls, cognitive decline, strokes and even death, it's a potentially significant inequality which we should take seriously, "  she said.  " More work may need to be done to ensure that guidelines are being consistently met, and that dementia services are culturally competent."

While previous studies looking at  American and Australian dementia patients have also found disparities in drug treatment for minority ethnic groups, this is the first time the issue has been investigated in a large UK study.   It also highlights the need for greater vigilance on the part of family members to avoid the dangers associated with overmedication and to make sure that their loved ones with dementia are getting the best possible care.  

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