Mental health implications for older adults after natural disasters

cyclone yasi_earthquake2

The January International Psychogeriatrics Article of the Month is entitled “Mental health implications for older adults after natural disasters – a systematic review and meta-analysis” by Georgina Parker, David Lie, Dan J. Siskind, Melinda Martin-Khan, Beverly Raphael, David Crompton and Steve Kisely. This blog piece was written for us by one of the paper’s authors, David Lie.

Our interest in the susceptibility of older adults to disaster arose in the context of an unprecedented spate of natural disasters and dramatic events affecting the Australia- New Zealand region between 2009 and 2011.

New Zealand was affected by an air crash, earthquakes (notably Christchurch) and the Pike River Mine accident. A number of bushfires affected most regions of Australia notably the Black Saturday fires, which itself had followed a heatwave. Flood and cyclone preoccupied other parts of the country (e.g. Cyclone Yasi) amidst economically disruptive events such as volcanic ashclouds. Taken together these events killed hundreds of people and injured or displaced thousands more.

The broad psychological impact of the Tohoku earthquake, tsunami and nuclear disaster complex was the closing parenthesis for a period that demanded we knew more about the psychiatry of extreme events and particularly for older adults. Very little seemed to have been written as overview with the exception of a narrative review by Cherniak (2008) and a book on geriatric aspects of disaster psychiatry (2010).

As we explored the literature, contradictory themes emerged suggesting that older people were as likely, more likely or less likely than younger counterparts in their susceptibility to serious mental health sequelae after disasters.

Four broad theories to explain age-related resilience or vulnerability are outlined in the introduction to our paper which can be summarised as:

  • Experience counts
  • You don’t react emotionally as much as you age which is protective
  • The middle aged are stressed most, caring for their children and parents
  • As you age you become more vulnerable

We chose to analyse the highest quality research to determine broad patterns but much more needs to be learned. Our research (Parker et al., 2016 this issue) showed increased relative risk for PTSD and adjustment disorder but is based on particular disasters in particular contexts and only on natural disasters. Our included studies were characteristically events which were sudden, unheralded and producing significant physical destruction comprising four earthquakes and two tsunamis.

It could be that older adults actually have better outcomes in disasters where evacuation and/or preparation are possible or in areas where natural disasters such as hurricanes or cyclones are recurrent and an eventual part of life for those who live long enough.

We would certainly recommend further development of standardised, validated tools and research protocols for deployment in future disaster psychiatry studies to expedite our understanding. Whatever the reality of climate change, the world is indisputably ageing and increasingly living closer to shorelines and other places that put people “in harm’s way”.

The full paper “Mental health implications for older adults after natural disasters – a systematic review and meta-analysis” is available free of charge for a limited time here.

The commentary paper “Natural disaster, older adults, and mental health–a dangerous combination” by Meaghan L. O’Donnell and David Forbes is also available free of charge here.

References:

Cherniack EP.. The impact of natural disasters on the elderly. Am J Disaster Med. 2008 May-Jun;3(3):133-9.

Parker G, Lie DC, Siskind DJ, Martin-Khan M, Raphael B, Crompton D and Kisely S. Mental health implications for older adults after natural disasters – a systematic review and meta-analysis. Int Psychogeriatrics 2016 (2016), 28:1, 11–20

Geriatric mental health disaster and emergency preparedness. John A. Toner,
editor ; Therese M. Mierswa, associate editor, Judith L. Howe, associate editor.

Poisoning among older people with dementia

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The November International Psychogeriatrics Article of the Month is entitled “Dementia and intentional and unintentional poisoning in older people: a 10 year review of hospitalization records in New South Wales, Australia” by Rebecca J. Mitchell, Lara A. Harvey, Henry Brodaty, Brian Draper and Jacqueline C. T. Close.

This blog post was written for us by one of the paper’s authors, Rebecca Mitchell.

Older people who have dementia are hospitalized far more commonly than people without dementia. One of the most common reasons that older people with dementia are hospitalized is due to injuries, with poisoning one of the most common types of injury experienced. Some poisonings may be unintentional mistakes, but others are due to a person intentionally trying to harm themselves.

It is not surprising that older people with dementia might experience difficulty with taking different doses of medication on specific days or at specific times. In this study, we wished to identify if older people with dementia had a higher rate of being hospitalised following poisoning than people without dementia and to try to identify commonalities surrounding the circumstances of the poisoning event that would allow us to raise awareness of approaches needed to prevent future poisonings.

Most research that has looked at older people with dementia and poisoning has involved small studies that examined admission at only one or two hospitals. In this study, we were able to examine all hospital admissions following poisoning of older people in the largest state in Australia, New South Wales, and to identify the circumstances of the poisoning event for both people with and without dementia.

Our research found that older people with dementia had double the rate of hospitalisations for unintentional poisoning and one and a half times the rate of hospitalisation for intentional poisoning compared to older people who did not have dementia. We identified that anticholinesterase medications (taken for Alzheimer’s disease), antihypertensive drugs and laxatives were the common medications taken by an older person with dementia when they unintentionally poisoned themselves. The home was the most common location of the poisoning, but unintentional poisoning was 5 times more likely to occur in aged care facilities and at least 4 times more likely to occur in health service facilities compared to intentional poisoning.

As all people age, the number of medications they take generally increase, with around 4 or more medications taken by people aged 60 years and older. It is more common for mistakes with medications to be made, the higher the number of medications that need to be taken. The presence of dementia is only likely to increase the potential for errors to be made and make problems of adherence to a medication regimen more difficult.

The findings of our study suggest that there are opportunities to prevent unintentional poisoning by older people with dementia by improving medication storage options, such as the use of blister packs or Dosette boxes, by getting family members or carers to assist in medication administration and, in the aged care and hospital settings, by ensuring quality use of medicines, and accurate documentation and review regarding polypharmacy.

The full paper “Dementia and intentional and unintentional poisoning in older people: a 10 year review of hospitalization records in New South Wales, Australia” is available free of charge for a limited time here.

The commentary paper “Poisoning among older people with dementia: a wake up call” by Christopher D. Etherton-Beer is also available free of charge here.

International Psychogeriatrics – Special issue on Young Onset Dementia

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International Psychogeriatrics
has published a special issue on Young Onset Dementia, guest edited by Raymond Koopmans and Tor Rosness.

The rising prevalence of dementia includes an increase of people with Young Onset Dementia (YOD). Studies have scrutinized the literature and documented distinct differences in traits between younger and older persons with dementia in several areas such as medical treatment, physical activity, functional level, activities of daily living, comorbidity, risk profiles, and caregiver distress. However, the cut-off of 65 years is arbitrary and there is still no consensus on if a diagnosis of dementia has to be made before the age of 65 years or if it is sufficient that the first symptoms are detected before the age of 65 years?

YOD is being steadily recognized as an important psychosocial and medical health problem with specific-age-related adverse consequences for both these younger persons and their families, however, many countries lack specific plans in their dementia strategies and do not offer any specific form of services or support for this group of individuals. Therefore the International Psychogeriatric Association (IPA) established a taskforce on YOD. The idea of composing a special issue on YOD was raised during The Hague meeting in 2011, and the issue consists partially of papers that have been presented during the symposia and workshop-meetings of the taskforce.

The YOD special issue provides an overview of important topics including unmet needs of carers, different clinical approaches to YOD diagnoses, needs of children with YOD parents, and medical treatment of behavioral symptoms of YOD patients.

We are offering limited time free access to the articles from this issue – simply register using our short form, using the code IPGYOD2

A positive attitude to ageing

 

Lothian cohort corrected

The September International Psychogeriatrics Article of the Month is entitled ‘Life course influences of physical and cognitive function and personality on attitudes to aging in the Lothian Birth Cohort 1936’ by Susan D. Shenkin, Ken Laidlaw, Mike Allerhand, Gillian E. Mead, John M. Star and Ian J. Deary.

 

The population is ageing, with the proportion of people worldwide aged over 60 rising from 8% in 1950, to 10% in 2000 and 21% in 2050 1. This has led to widespread concern about the negative impact this may have on society. We were interested in exploring whether older people themselves share this negative view of ageing, or whether they might have a more positive outlook. We were also interested to explore what factors throughout their life predicted their attitudes to ageing.

We were able to do this using a group of people who have had detailed information collected about them throughout their life, and asking them to complete (another!) questionnaire. This freely available questionnaire 2 has been widely used to assess the experience and attitudes of older people themselves to ageing. It includes questions in three main areas called Psychosocial Loss (e.g. “Old age is a time of loneliness”), Physical Change (e.g. “I don’t feel old”), and Psychological Growth (e.g. “Wisdom comes with age”), which people scored from ‘strongly disagree’ to ‘strongly agree’.

The group of people who completed the questionnaire were the Lothian Birth Cohort 1936 3. These are people born in 1936 who sat a nationwide test of intelligence when they were aged 11, and have gone on to provide very detailed information about their life, including their health and cognition now they are older.

We found that these people (aged around 75, 51.4% male) were generally positive about the three aspects of ageing. When we explored what predicted these attitudes, we were surprised to find that their social background, IQ test scores and physical health didn’t relate very much to their attitudes. In general, the strongest predictors of their attitudes to ageing was their personality. Personality type is determined by a questionnaire 4.

Psychosocial loss (e.g. “I feel excluded from things” was more common in people with personalities stronger on Neuroticism, and lower on Extraversion, Openness, Agreeableness and Conscientiousness, but also people with higher scores on a questionnaire assessing anxiety and depression, and people with more physical disability.

Physical Change (e.g. “My health is better than I expected”) was predicted by people with personality types of Extraversion, Openness, Agreeableness and Conscientiousness, but also females, social class and less physical disability.

Psychological growth (e.g. “I am more accepting of myself”) was associated with similar personality types, but surprisingly a less affluent environment, living alone, lower prior cognitive ability and slower walking speed.

In general, in this group of relatively healthy volunteers in Scotland aged around 75 we found a positive attitude to ageing. These attitudes were mostly associated with personality type, but social circumstances, physical health and mood also played a role. It will be interesting to explore whether attitudes are similar or different in other groups e.g. in people with poorer physical or mental health, in different countries etc. An intriguing possibility is whether influencing people’s attitudes is possible, and might result in changes to mood or physical health. However, it is clear that we should all share a more positive view of our ageing society.

 

The full paper “Life course influences of physical and cognitive function and personality on attitudes to aging in the Lothian Birth Cohort 1936” is available free of charge for a limited time here.

The commentary on the paper, “Positive attitudes on aging: a life course view” is also available free of charge for a limited time here.

 

References

1) http://www.un.org/esa/population/publications/worldageing19502050/

2) Attitudes to Ageing Questionnaire – AAQ (Laidlaw, K., Power, M. J. and Schmidt, S. (2007). The Attitudes to Ageing Questionnaire (AAQ): development and psychometric properties. International Journal of Geriatric Psychiatry, 22, 367–379

3) http://www.lothianbirthcohort.ed.ac.uk/index.php?option=com_content&view=article&id=7&Itemid=2 and Deary, I. J., Gow, A. J., Pattie, A., & Starr, J. M. (2011). Cohort Profile: The Lothian Birth Cohorts of 1921 and 1936. International Journal of Epidemiology. doi: 10.1093/ije/dyr197

4) (NEO-FFI: Costa, P. T. and McCrae, R. R. (1992). NEO PI-R and Professional Manual (Revised NEO Personality Inventory and NEO Five-Factor Inventory). Odessa, FL: Psychological Assessment Resources).

 

Image: ““Lothian Birth Cohort 1936 at a reunion in Edinburgh, 2007.  Credit: Douglas Robertson/Age UK”

www.lothianbirthcohort.ed.ac.uk

Photographers website: www.douglasinscotland.co.uk

 

Mind over matter

Family Fun

The June International Psychogeriatrics Article of the Month is entitled ‘Mind over matter – what do we know about neuroplasticity in adults?’ by Vyara Valkanova, Rocio Eguia Rodriguez and Klaus P. Ebmeier

 

Until recently the capacity of the human brain for structural and functional reorganization (brain plasticity) was considered to be limited to critical periods during development. Neuroimaging provides a non-invasive window into the living brain and has been used to study different aspects of brain plasticity during the learning of new skills or after novel experiences. We reviewed the strongest neuroimaging evidence for experience-dependent plasticity in adult humans, and therefore focused on longitudinal studies only (i.e. participants are scanned before and after different interventions, and then the images are compared).

We identified 36 studies that employed different types of training, such as juggling, exercising working memory, meditation, learning abstract information (studying for exams), and aerobic exercise. Although different patterns of results were found, there was consistent evidence that the brain (gray as well as white matter – brain cells as well as neuronal connections) retains much greater plasticity in adults (<75 years old) than is traditionally thought.

Before such research results can be translated into medical practice, there are many questions that still need to be answered. We currently do not know enough about the type and duration of the interventions that are effective, about the upper limits of improvement, how gains can be maintained, and most importantly the exact relationship between structural change and functional improvement. Further, all reviewed studies are in healthy individuals, while the impact of such interventions in patients with dementia is less well studied.

Future research will need to include larger samples and standardised training protocols to allow comparison of studies done at different research centres. Animal studies combining imaging with histological studies [detailed microscopic analysis] can be very useful in understanding the cellular mechanisms underlying learning, which is important when devising effective interventions. Finally, a multimodal imaging approach, where measures derived from complementary imaging modalities is likely to play a major role in increasing our understanding of brain plasticity. It is possible today, for example, to examine the volume of brain grey matter, the quality of anatomical connections between different areas of the brain and the degree of cooperation between different regions of the brain during the same examination, in other words to examine structural and functional brain connectivity. We know now that even the adult brain has a significant potential to change and compensate for any damage, for example after a stroke. Research in this area will have important implications for our ability to harness the natural self-healing and compensation properties of our brains to the greatest effect, in neurodegenerative diseases such as the dementias.

 

The full paper “Mind over matter – what do we know about neuroplasticity in adults?” is available free of charge for a limited time here.

The commentary on the paper, “Expanding the mind – growing the brain…” is also available free of charge for one month here.

 

The relationship between C-RP and delirium and its severity

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The May International Psychogeriatrics Article of the Month is entitled ‘The association between C-reactive protein and delirium in 710 acute elderly hospital admissions’ by C.W. Ritchie, T.H. Newman, B. Leurent and E.L. Sampson.

Delirium is a common but poorly understood condition that primarily affects elderly patients; it is defined as having an acute onset and fluctuating course with deficits in attention, arousal state and perception and is associated with poor outcomes. The burden delirium places on the healthcare system will only increase as the ageing population grows, which means improvements in prediction, diagnosis and management are necessary. Whilst peripheral inflammation is a recognized precipitant of delirium, and evidence supports a neuroinflammatory basis, the role that the inflammatory marker C-reactive protein (C-RP) plays has not been defined. C-RP is regularly measured and is raised in many conditions which are associated with delirium however studies investigating C-RP’s relationship with delirium show contrasting results.

Our study took a large population of elderly patients who were admitted to hospital after presenting acutely and investigated the relationship between C-RP and delirium. Published in the May edition of International Psychogeriatrics the article describes the finding that C-RP was associated with delirium independent of other risk factors but not with delirium severity. On sub-group analysis this association remained in those patients who suffered musculoskeletal problems such as fractures and traumatic injuries. To our knowledge this was the largest study to date which investigated this relationship in a general elderly population.

These observations suggest that C-RP may represent a major factor in the genesis of delirium secondary to musculoskeletal damage. Additionally C-RP could act as a marker for current or incipient delirium and as such may form part of a risk score to aid recognition of at risk patients. Importantly it must be noted that longitudinal studies are necessary in order to establish a timeline to this relationship.

Furthermore this study adds weight to the neuroinflammatory hypothesis underlying delirium genesis and proposes that whilst C-RP may be important in musculoskeletal cases it is unlikely to be part of a unifying pathway leading to the common end point that is delirium. Future studies should investigate this relationship as well as other inflammatory mediators to further our understanding of delirium.

 

The full paper “The association between C-reactive protein and delirium in 710 acute elderly hospital admissions” is available free of charge for a limited time here.

The commentary on the paper, “Delirium really matters” is also available free of charge for one month here.

The effect of exercise on cognitive outcomes in Alzheimer’s disease

Seniors jogging on a forest road

From January 2014, International Psychogeriatrics will be choosing a paper of the month. It is selected by the editorial team to point out a review or an original contribution which they think should be of great interest to most readers. Each paper of the month will be accompanied by a short commentary, provided by an editor, reviewer, or expert in the field.

The first of these is a systematic review on the effect of exercise on cognitive outcomes in Alzheimer’s disease (AD) by Farina et al.

With the global aging of our societies and predicted increase of cognitive impairment and dementia, it is no surprise that there is an increasing interest not only in the research community, but also among clinicians and the general population to learn more about how to focus on modifiable protective factors and how to avoid modifiable risk factors.

However, we should not forget about the various stages of prevention, and especially in the field of psychogeriatrics should also ask what preventative measures might be effective for older adults who have already experienced cognitive impairment.

The number of randomized controlled trials (RCT) investigating the effectiveness of physical activity on cognition is limited for healthy participants and those with MCI, but is even more sparse for those with dementia.

In the January issue of International Psychogeriatrics, Farina and colleagues publish a systematic review titled “The effect of exercise interventions on cognitive outcome in Alzheimer’s disease: a systematic review”. This paper will help readers of International Psychogeriatrics to critically review the evidence for physical activity and cognition provided by RCTs in patients with AD.”

The paper reviewed six studies that considered the effect of exercise in AD patients. Following analysis, the results suggest that exercise can have a positive effect on the rate of cognitive decline. This finding is encouraging and should be considered as another piece of evidence to encourage physical activity for older adults with AD.

While the overall positive result of this systematic review is promising, the limitations when interpreting this finding are plentiful, which Farina and colleagues thoroughly discuss in their paper. Most importantly, the number of studies included and the number of participants in these studies are small, which is a reminder that this area of research is still in its infancy.

The editorial team of International Psychogeriatrics selected this systematic review as paper of the month, since next to reviewing the evidence it discusses in detail what further research is needed in this important area. We also want to encourage other authors who consider writing systematic reviews in the field of psychogeriatrics to consider a submission to International Psychogeriatrics.

The full paper “The effect of exercise interventions on cognitive outcome in Alzheimer’s disease: a systematic review” is available free of charge for one month here.

The commentary on the paper “Physical activity in Alzheimer’s disease: research in its infancy or why we need more randomized controlled trials” is also available free of charge for one month here.

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