Late-life depression

There is a strong focus on mental health problems in later life in the Journal this month, with three papers addressing late-life depression. Depression in later life has been found to be associated with a range of neurobiological findings, but studies reliant on neuroimaging techniques have typically been limited by small and highly selected samples. Using near-infrared spectroscopy as a portable non-invasive test of cerebral perfusion, an association between clinically significant depressive symptoms and lower frontal lobe perfusion after standing was found in a large sample of community-dwelling older people (Briggs et al, pp. 230–236). Further analyses revealed that the association only persisted over time (30, 60, 90 s) in those with low systolic blood pressure. The authors highlight low blood pressure as a potential treatment target for reducing incident depression in older people and note previous research establishing a longitudinal association between lower blood pressure and depression in older samples.

Fancourt & Tymoszuk (pp. 225–229) consider the potential of a very different approach to preventing onset of depression in older adults, utilising data from the English Longitudinal Study of Ageing to focus on cultural engagement. They identified a dose–response relationship between frequency of cultural engagement activities and later risk of developing depression over a 10-year period, equating to a 32% lower risk for those attending activities every few months and a 48% lower risk for those attending at least once per month. The association was found to be independent of a range of covariates and was robust to consideration of the potential for reverse causality. Engaging in cultural activities regularly (including the cinema, theatre, galleries, concerts, opera) may reduce risk of depression via a number of potential mechanisms, including social interaction and cognitive stimulation, for example.

In a randomised controlled trial of a novel intervention for late-life depression by Ionson et al (pp. 218–224), Sahaj Samadhi meditation (SSM) was found to be associated with improvements in depressive symptoms, but not in heart rate variability, compared with a treatment-as-usual control group. The authors call for future research on SSM in late-life depression to include active control arms, to consider the dose of intervention required for efficacy, to measure the long-term impact of treatment, to include cost–benefit analyses and to include samples of individuals with recent cardiovascular events in order to increase the potential for identifying associations between receiving SSM treatment and measures of heart rate variability.

Dementia – decision-making and staff training

Aiming to move beyond global assessments of patient involvement in dementia treatment decision-making, Dooley et al (pp. 213–217) undertook detailed analyses of video-recorded diagnostic meetings from nine memory clinics. Doctors overwhelmingly nominated people with dementia as the decision-maker in these meetings but over 80% of patients did not express clear acceptance of recommendations for medication, with those recommendations taking the form of suggestions, proposals, assertions, pronouncements and offers, in decreasing frequency. Patient's acceptance of, or resistance to, medication did not influence medication prescription nor was there any association found between cognitive impairment and recommendation format. Although not specifically focused on decision-making capacity in dementia, an editorial by Zhong et al (pp. 183–185) recommends a pragmatic approach to helping capacity evaluators resolve difficult cases in those patients where partial impairment is apparent.

In light of the increasing numbers of older people with cognitive impairment presenting for treatment in general hospitals, Abley et al (pp. 201–212) have reviewed the evidence on education and training programmes designed to prepare staff for caring for this patient group. All of the studies focused on delirium reported increased post-intervention knowledge and two of the studies on dementia reported increased knowledge and confidence, but the quality of included studies was low. The authors highlighted the importance of measuring patient outcomes in studies of this type.

Self-harm in older adults

Although populations are ageing and the occurrence of mental health problems and suicide rates are known to be high in later life, little is known about patterns of self-harm in older adults. Following a systematic review of the relevant literature, Troya et al (pp. 186–200) found evidence that self-harm in later life has distinct characteristics. Reported motivations for self-harm included loss of control, increased loneliness and the perceived burdensomeness of ageing; physical health problems were also commonly reported. The authors highlight the potential for clinicians to intervene to reduce risk of repetition and of suicide in this group given the higher rates of reported contact with health services.