It’s difficult to get excited about old age psychiatry. Often seen as the “palliative” end of psychiatry, there is a reluctance to see much of a benefit with regards to looking after older people, let alone excited about it. It also does not appear to be an arena with much regarding change – how many ways, after all, can one start antipsychotics for dementia?
In that itself, however, is where change can be demonstrated – the average psychogeriatrician stopped using antipsychotics as first line for behaviour control more than a decade ago. But let’s go further than that – here are four areas to get excited in old age psychiatry. And they’re all to do with the same thing – the holy grail of old age psychiatry (and, arguably, neurological health in general) – preventing dementia.
It may not appear relevant for the average older person – surely, the population most famed for impaired renal functioning could not possibly benefit from this agent. However, there are unusual issues with it.
As a multi-target drug, given activity in several intracellular cascades and oxidative stress pathways, it has been thought to have neuroprotective features and found to improve learning and memory in animal models. In 2014, a systematic review of standard and trace-dose lithium identified 24 studies, within which 4 small randomized clinical trials of lithium found at least some clinical or biological benefits versus placebo, outside of control of bipolar disorder.
Then, it was found to potentially reduce the incidence of dementia. Multiple reviews looking at drinking water contamination have found a reduced incidence of dementia. It has been proposed that it has some role in mitigating lead exposure related deterioration, but then it has also been found to have benefits in large epidemiological studies. Those with known bipolar disorder who were prescribed lithium were found to have reduced rates of dementia.
Again, however, its renotoxicity is problematic. However, in 2019 Forleza and associates published a double-blind, placebo-controlled trial of low-dose lithium among patients with mild cognitive impairment. We know that mild cognitive impairment is identified high risk group for progression to dementia. Forlenza’s study cut that risk in half. This was even when the lithium doses were not in “therapeutic” range – meaning, of course, that the clinical risk was considerably less.
Several studies are proceeding right now replicating Forlenza’s approach. If wider consensus is obtained with regards to dosing and safety, this could be the next great revolution in dementia prevention.
It seems counterintuitive to discuss lifestyle interventions after pharmacotherapy. But whilst the jury is still out on all other interventions described here, the evidence for exercise is considerably better clarified. A systematic review in 2019 (of 46 trials with 5099 participants) estimated a reduction in the decline of global cognition, with a standardised mean difference of 0.44 (95% CI 0.27 to 0.61). It even appears to reduce global cognitive decline and reduce behavioural problems in people with MCI or dementia. Most evidence appears to be in aerobic exercise, but the most fascinating element is that best evidence was for a total of over 24 hours of exercise, regardless of frequency. Best news is that this, compared to anything else in this article, is ready for prescription immediately.
To return to the counterintuitive, psychotherapy in older people is rarely seen as a priority in mental health, and disappointingly given the excellent evidence for its applications, when appropriate assessments and adjustment for age related issues is used. However, this appears to be a niche within a niche within a niche. Psychodynamic therapy for patients with dementia?
As Alzheimer’s dementia in particular is associated with declarative memory, but there is the controversial term of “emotional memory” which has been described as appearing well preserved even in late stage Alzheimer’s. A case series was published describing emotional memory persisting several weeks after notable life events, despite the factual knowledge of the life events not being retained.
Given this, it should not be surprising that an intervention that explicitly deals with emotional memory – in responding to the unconscious and emotional validation – can be of benefit in dementia. A textbook was recently published regarding psychodynamic approaches to dementia, noting multiple perspectives and experiences regarding its impact. Endorsed by no less than Sube Banerjee and Peter Fonagy, it carries unique ideas which are not at all mainstream, but nevertheless evidence based. Most regard dementia as when cognitive impairment crosses the line to impact negatively on socio-occupational functioning. If the psychodynamic impact of cognitive loss can be controlled through therapy, does this not also control the presence of dementia per se?
Recently, the college received an unusual request, to validate an item number for imaging and CSF studies that would determine levels of amyloid accumulation. On its own, this may appear buried between a number of administrative tasks, but it is part of the upcoming – and divisive – potential tsunami of pharmacotherapeutic treatments that are thought to be effective in preventing an incurable condition.
What must firstly be noted is that it is not hyperbole to say that billions has been spent on failed dementia-related trials. Many pharmaceutical representatives, in remarkable moments of honesty, have expressed fatigue to me regarding the issue. However, where aducanumab – and other similar upcoming agents – potentially change the game is the target population. The drug failed to be effective in established dementia, but received approval by the FDA in the US in June 2021 specifically for early Alzheimer’s, which appears to be validated by clinical trials. Again, this is not without controversy – three advisers to the FDA resigned following the approval.
Nothing has worked consistently for established dementia. But, what if this encourages us to think about those conditions which are progressing towards dementia, and implement interventions at that stage before the disease sets in? The risks, in some cases, are considerable. But, if any – or, potentially, all – of the above work, the condition that causes the greatest pain to the human population may be finally tamed.
And that is exciting.
Mauer S, Vergne D, Ghaemi SM. 2014. Standard and trace-dose lithium: a systematic review of dementia prevention and other behavioral benefits. Aust N Z J Psychiatry 48(9): 809-818.
Jeyasingam N. 2020. Lithium to Treat – Or Prevent – Dementia: A Short Discussion. J J Neurol Exp Neurosci 6(1): 13-15.
Law CK, Lam FM, Chung RC, Pang MY. Physical exercise attenuates cognitive decline and reduces behavioural problems in people with mild cognitive impairment and dementia: a systematic review. J Physiother. 2020 Jan;66(1):9-18. doi: 10.1016/j.jphys.2019.11.014. Epub 2019 Dec 13. PMID: 31843427.
Jeyasingam NR. Psychotherapy and the older person. Australasian Psychiatry. 2017;25(3):225-226. doi:10.1177/1039856216689526
Okada A, Matsuo J. Emotional memory in patients with Alzheimer’s disease: a report of two cases. Case Rep Psychiatry. 2012;2012:313906. doi:10.1155/2012/313906
Psychodynamic Approaches to the Experience of Dementia: Perspectives from Observation, Theory and Practice. Edited by Sandra Evans, Jane Garner, Rachel Darnley Smith. 2020, Routledge.
McGinley L (9 June 2021). “Two members of an FDA advisory committee quit after approval of controversial Alzheimer’s drug”. The Washington Post.
(The above article includes information published in MindCafe)