By Sorcha Daly - author of Inequalities in Mental Health, Cognitive Impairment and Dementia among Older People
Sixty thousand people die each year from symptoms directly attributable to dementia, and 25% of older people are diagnosed with depression, rising to 40% in residential care homes. These conditions, along with mild cognitive decline (MCI) are often seen as an inevitable part of ageing.
Depression, of course, can happen to anyone. Indeed, many people with full and successful lives experience depression at some point in their lives, and particularly in later life as the result of bereavement, retirement or other significant life events. Similarly, mild cognitive impairment (MCI) is also accepted as an unavoidable part of getting older, as is dementia, if genes, family history, or even luck, are not on your side. However, although factors such as genes, and significant life events, are important, and often unavoidable, they only make up part of a picture that predicts increased risk of experiencing poor mental health, MCI and dementia in later life.
Our report Inequalities in Mental Health, Cognitive Impairment and Dementia among Older People examined the roles of life course drivers for poor mental health, MCI and dementia and found that the likelihood of having poor mental health, MCI or dementia in later life is not distributed evenly across the UK. Social determinants of health across the life course will not only result in shorter life expectancy, but can also result in more of that shorter life spent in ill health and disability, and this includes poor mental health, MCI and dementia.
These inequalities can be exacerbated in later life by a range of factors. Our report focused on unequal access to social connectedness, mental stimulation and physical exercise, and the social, economic and environmental conditions that drive and widen inequalities in access to these important social determinants of health.
Life course drivers:
Education is important. ‘Cognitive reserve’, meaning the skills, abilities and knowledge that increase the resilience and adaptability of the brain and its functioning, is built throughout the life course and increases the efficiency and flexibility of the brain, helping to reduce the risk, delay the onset, and ameliorate the symptoms of mild cognitive impairment and dementia in later life. Higher levels of education increase ‘cognitive reserve’, and some of the latest evidence demonstrates that children who attain higher grades in school, and then go on to occupations with high levels of complexity, have a lower risk of experiencing dementia.
There are other significant life course drivers. Poor quality, sporadic employment or unemployment can lead to job strain, increase the risk of later life poor mental health, in addition to increasing the risk of musculoskeletal conditions and more sedentary lives, whilst simultaneously reducing the levels of lifetime income needed to build material resources for a good standard of living in later life. The built and green environment also has a significant role. Good quality, well maintained green space, safe, walkable neighbourhoods and appropriate housing are all important drivers for improved life time health.
But these life course social determinants are not evenly distributed in the UK, and areas of deprivation are less likely to have these essential, health promoting environments, increasing the risks of developing cardio vascular and respiratory conditions that are linked to mild cognitive impairment and dementia.
Later life drivers:
These conditions also increase the risk of developing poor mental health in later life, can speed up the rates of cognitive decline, and increase the risk of earlier onset of dementia. They also decrease the financial and social resources available to cope with depression, or the symptoms of mild cognitive impairment or dementia when they occur.
Poverty in older age, poor housing conditions and poorly maintained neighbourhoods and green space, influence levels of later life physical activity, mental stimulation and social connectedness. This is important because evidence demonstrates that cognitive reserve is not fixed, and can be built in later life through access to mental stimulation, reducing the risk and speed of cognitive decline, and delaying onset of dementia symptoms. So, although mild cognitive impairment and dementia, for some of us, may be inevitable, the severity of its symptoms, the impact it has on our lives, and the resources we have to cope with the conditions are modifiable and depend on our environmental, economic and social resources.
Equally, depression does not have to be an inevitable part of growing old. Many older people can, and do, stay socially connected and lead full and purposeful lives. But almost a third of people over 80 report high levels of loneliness and in 2014 1million older people reported not speaking to anyone in over a month. This not only causes poor mental health and depression but is also life threatening.
There is also evidence demonstrating that depression can hasten the conversion of mild cognitive impairment to dementia. Again, the social, economic and environmental risk factors for depression and loneliness in later life are modifiable and these risk factors affect people in lower socio economic groups disproportionately. Within these groups women, Black and Minority Ethnic groups, people with disabilities, and carers are more at risk of both life time and later life conditions that increase the risks of poor mental health, mild cognitive impairment and dementia and decrease the resources needed to cope with the conditions.
There are legal, economic and social justice reasons for taking action on the social determinants that increase the risks of poor mental health, cognitive impairment and dementia. Caring for people with dementia costs £26 billion per year in health and social care, and more in informal care from family members. Postponing the onset of dementia by just two years could save £52 billion.
Developing policy and interventions which create the physical and economic environments that enable all older people to be active, socially connected and contributors in their own communities will drive economic development and save costs to the public purse and could result in a net economic contribution reaching £8 billion by 2030.
At present, and historically, Government policy places greater emphasis on diagnosis and access to treatment rather than addressing the main drivers for the inequalities found in poor mental health, MCI and dementia. But the inequalities in prevalence of poor mental health, MCI and dementia, which are unjust and avoidable, are driven by social, economic and environmental factors. Without urgent action to address these factors the burden of ill health will continue to fall, disproportionately – and unnecessarily – on the less advantaged.