Mental Health Horizon Scanning Dr Cameron Stark

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1 Introduction Mental Health Horizon Scanning Dr Cameron Stark There were a number of papers on dementia, in the search, and this was the only consistent theme. I have supplemented them with a separate literature review on dementia. Impact Dementia increases with age, with very high rates in the oldest old ( Gao, Hendrie et al. 1998), and some suggestion that rates in this group may be increasing (Mathillas, Lovheim et al. 2011). Current trends in ageing will, with no other change, result in substantially increased numbers of people with dementia(roc ca, Petersen et al. 2011). As people with dementia have high care costs, this produces a greater increase in health and social care costs than would be expected from the increase in the older population. This is further complicated by changes in risk factor prevalence. Most current estimates, and all of those in the UK, assume that current age-specific rates will continue. This is unlikely. The neuropathology of Alzheimer s Disease, and of vascular dementia, have become clearer, and have more in common than previously understood. Genetic factors are important, including the well-publicised ApoE e4 (Ashford 2004), but other factors account for greater population attributable risk (Ritchie, Carriere et al. 2010). Increasing educational level (Scazufca, Almeida et al. 2010) and job complexity are associated with lower risk. Obesity (Gustafson, Backman et al. 2009), diet (Feart, Samieri et al. 2009), diabetes (Luchsinger 2010a, Luchsinger 2010b), exercise levels (Rolland, Abellan van Kan et al. 2010), depression (Dotson, Beydoun et al. 2010, Saczynski, Beiser et al. 2010, Butters, Young et al. 2008) and hypertension (Launer, Hughes et al. 2010, Ligthart, Moll van Charante et al. 2010, Razay, Williams et al. 2009) are particularly important risk factors, and affect both Alzheimer s and Vascular Dementia rates. These risk factors appear to interact with genetic risk. Modelling suggests that factors such as population exercise levels may have an important impact on dementia risk. While this is hopeful for prevention, it does mean that the increase in many of these adverse risk factors can be expected to increase rates of dementia, and so of impact on services. Recent UK modelling indicates that the decline in care home beds will leave a deficit for the current rate of institutionalisation in dementia, even with current rates. There is no persuasive evidence that reversing these factors decreases dementia, but the United States, Australia and England have taken the view that pragmatic actions are required. Scotland has a limited programme, run by Alzheimer Scotland and previously supported by NHS Health Scotland ( Good for you, good for your brain ). Even modest preventative success would reduce numbers (Jorm, Dear et al. 2005), although the care requirements would still be substantial (Brayne, Gao et al. 2006). 1

2 There is considerable drug-trial activity in this area and, while long-term savings from new treatments could be substantial, it would be very likely that drug costs would be high. Required Public Health action falls in to four areas: Reducing dementia incidence Continuing work on healthy lifestyles (Desai, Grossberg et al. 2010, Savica, Petersen 2011, Richard, Van den Heuvel et al. 2009), possibly with additional targeted work at people at high genetic risk (Reitz, Mayeux 2010). Slowing Progression There are two trials underway on treatment of vascular risk factors in people with dementia, as observational studies suggest that this may reduce the rate of progression (Deschaintre, Richard et al. 2009, Duron, Rigaud et al. 2009). There is reasonable evidence that Cognitive Stimulation improves symptoms. The optimum frequency of treatment, and some issues on treatment options are not yet clear, however, and several trials are underway. Decreasing Speed of Movement to Institutional Care Changes in health state including from community living to institutional care are very important. Services to support people at home are of obvious importance, particularly given the evidence on the inadequacy of current institutional provision. Telecare is likely to be important, but changes in service philosophy and public attitudes may also be required. Decreasing Sequelae Falls are a particular problem (Allan, Ballard et al. 2009, Tangman, Eriksson et al. 2010). Dementia increases risk of falls, and beginning to fall can be an early sign of dementia. Rates may be increased by anti-psychotic use, and with multiple drug use (Sterke, Verhagen et al. 2008). When people fall, and are admitted to hospital, all the usual problems of hospital treatment are exacerbated by their cognitive impairment. It may be possible to reduce falls (Lahat, Muller 2009). Conclusions The literature review identified dementia as a recurrently identified theme. There is good evidence of rapid impact on services, and of Public Health requirements. NHS Highland plans dementia modelling taking risk factors in to account, and this may contribute to an improved Scottish picture of potential service requirements. Cameron Stark NHS Highland July

3 ALLAN, L.M., BALLARD, C.G., ROWAN, E.N. and KENNY, R.A., Incidence and prediction of falls in dementia: a prospective study in older people. PLoS ONE [Electronic Resource], 4(5), pp. e5521. ASHFORD, J.W., APOE genotype effects on Alzheimer's disease onset and epidemiology. Journal of Molecular Neuroscience, 23, pp BRAYNE, C., GAO, L., DEWEY, M. and MATTHEWS, F.E., Dementia before death in ageing societies - the promise of prevention and the reality. PLoS Medicine, 3(10), pp. doi: /journal.pmed BUTTERS, M.A., YOUNG, J.B., LOPEZ, O., AIZENSTEIN, H.J., MULSANT, B.H., REYNOLDS, C.F., 3RD, DEKOSKY, S.T. and BECKER, J.T., Pathways linking late-life depression to persistent cognitive impairment and dementia. Dialogues in Clinical Neuroscience, 10(3), pp DESAI, A.K., GROSSBERG, G.T. and CHIBNALL, J.T., Healthy brain aging: a road map. Clinics in geriatric medicine, 26(1), pp DESCHAINTRE, Y., RICHARD, F., LEYS, D. and PASQUIER, F., Treatment of vascular risk factors is associated with slower decline in Alzheimer disease. Neurology, 73(9), pp DOTSON, V.M., BEYDOUN, M.A. and ZONDERMAN, A.B., Recurrent depressive symptoms and the incidence of dementia and mild cognitive impairment. Neurology, 75(1), pp DURON, E., RIGAUD, A.S., DUBAIL, D., MEHRABIAN, S., LATOUR, F., SEUX, M.L. and HANON, O., Effects of antihypertensive therapy on cognitive decline in Alzheimer's disease. American Journal of Hypertension, 22(9), pp FEART, C., SAMIERI, C., RONDEAU, V., AMIEVA, H., PORTET, F., DARTIGUES, J.F., SCARMEAS, N. and BARBERGER-GATEAU, P., Adherence to a Mediterranean diet, cognitive decline, and risk of dementia. JAMA, 302(6), pp GAO, S., HENDRIE, H.C., HALL, K.S. and HUI, S., The relationship between age, sex and the incidence of dementia and Alzheimer's disease: a metaanalysis. Archives of General Psychiatry, 55, pp GUSTAFSON, D.R., BACKMAN, K., WAERN, M., OSTLING, S., GUO, X., ZANDI, P., MIELKE, M.M., BENGTSSON, C. and SKOOG, I., Adiposity indicators and dementia over 32 years in Sweden. Neurology, 73(19), pp JORM, A.F., DEAR, K.B.G. and BURGESS, N.M., Projections of future numbers of dementia cases in Australia with and without prevention. Australian and New Zealand Journal of Psychiatry, 39, pp

4 LAHAT, M. and MULLER, M., Striving for safety: a falls prevention initiative for home care clients with dementia. Caring, 28(8), pp LAUNER, L.J., HUGHES, T., YU, B., MASAKI, K., PETROVITCH, H., ROSS, G.W. and WHITE, L.R., Lowering midlife levels of systolic blood pressure as a public health strategy to reduce late-life dementia: perspective from the Honolulu Heart Program/Honolulu Asia Aging Study. Hypertension, 55(6), pp LIGTHART, S.A., MOLL VAN CHARANTE, E.P., VAN GOOL, W.A. and RICHARD, E., Treatment of cardiovascular risk factors to prevent cognitive decline and dementia: a systematic review. Vascular Health & Risk Management, 6, pp LUCHSINGER, J.A., 2010a. Diabetes, related conditions, and dementia. Journal of the neurological sciences, 299(1-2), pp LUCHSINGER, J.A., 2010b. Type 2 diabetes, related conditions, in relation and dementia: an opportunity for prevention? Journal of Alzheimer's Disease, 20(3), pp MATHILLAS, J., LOVHEIM, H. and GUSTAFSON, Y., Increasing prevalence of dementia among very old people. Age & Ageing, 40(2), pp RAZAY, G., WILLIAMS, J., KING, E., SMITH, A.D. and WILCOCK, G., Blood pressure, dementia and Alzheimer's disease: the OPTIMA longitudinal study. Dementia & Geriatric Cognitive Disorders, 28(1), pp REITZ, C. and MAYEUX, R., Use of genetic variation as biomarkers for mild cognitive impairment and progression of mild cognitive impairment to dementia. Journal of Alzheimer's Disease, 19(1), pp RICHARD, E., VAN DEN HEUVEL, E., MOLL VAN CHARANTE, E.P., ACHTHOVEN, L., VERMEULEN, M., BINDELS, P.J. and VAN GOOL, W.A., Prevention of dementia by intensive vascular care (PreDIVA): a clusterrandomized trial in progress. Alzheimer Disease & Associated Disorders, 23(3), pp RITCHIE, K., CARRIERE, I., RITCHIE, C.W., BERR, C., ARTERO, S. and ANCELIN, M., Designing prevention programmes to reduce incidence of dementia: prospective cohort study of modifiable risk factors. BMJ, 341. ROCCA, W.A., PETERSEN, R.C., KNOPMAN, D.S., HEBERT, L.E., EVANS, D.A., HALL, K.S., GAO, S., UNVERZAGT, F.W., LANGA, K.M., LARSON, E.B. and WHITE, L.R., Trends in the incidence and prevalence of Alzheimer's disease, dementia, and cognitive impairment in the United States. Alzheimer's & Dementia, 7(1), pp

5 ROLLAND, Y., ABELLAN VAN KAN, G. and VELLAS, B., Healthy brain aging: role of exercise and physical activity. Clinics in geriatric medicine, 26(1), pp SACZYNSKI, J.S., BEISER, A., SESHADRI, S., AUERBACH, S., WOLF, P.A. and AU, R., Depressive symptoms and risk of dementia: the Framingham Heart Study. Neurology, 75(1), pp SAVICA, R. and PETERSEN, R.C., Prevention of dementia. Psychiatric Clinics of North America, 34(1), pp SCAZUFCA, M., ALMEIDA, O.P. and MENEZES, P.R., The role of literacy, occupation and income in dementia prevention: the Sao Paulo Ageing & Health Study (SPAH). International Psychogeriatrics, 22(8), pp STERKE, C.S., VERHAGEN, A.P., VAN BEECK, E.F. and VAN DER CAMMEN, T.J., The influence of drug use on fall incidents among nursing home residents: a systematic review. International Psychogeriatrics, 20(5), pp TANGMAN, S., ERIKSSON, S., GUSTAFSON, Y. and LUNDIN-OLSSON, L., Precipitating factors for falls among patients with dementia on a psychogeriatric ward. International Psychogeriatrics, 22(4), pp