CitationDownload as .RIS
Emerald Group Publishing Limited
Article Type: Editorial From: Journal of Public Mental Health, Volume 14, Issue 1
Welcome to this Special Issue of JPMH on Dementia. In a Guest Editorial, Hoang et al. set out the Global context for this issue, beginning with the recent G8 summit on dementia. Given that our readers come from many different backgrounds, I will try to put our dementia theme within a wider public health context, below.
In the origins of "Social Medicine" in Germany and "Public Health" in Britain, communicable disease was the driver for change. There were significant consequences for mental health of infection with syphilis or hepatitis and in 1927 psychiatrist Julius Wagner-Jauregg won the Nobel Prize for his earlier work on General Paralysis of the Insane (neurosyphilis). When other topics were first added to population sciences, these related to death from external causes like transport accidents or house fires where insurance companies accumulated data. In the years preceding the First World War a priority for improved fitness in men of military age increased the knowledge of exercise and nutrition for health, but the long-term needs of women or men past fighting age seemed of little importance. Most working class people died before 60, anyway, so conditions of old age seemed a low priority then for public health. When, in 1906, Alois Alzheimer described the brain pathology and mental changes that we now call Alzheimer's disease, he captured the interest of his medical colleagues because he described a presenile patient with dementia he observed from age 51 to her death aged 55. Clinical psychiatry made advances during the 1914-1918 War for soldiers with "Shell Shock" (a wide spectrum of conditions including Post Traumatic Stress Disorder) but there was little ability to prevent more wars and so to prevent such mental disorder.
In 2014 as the UK, USA and many other countries plan for their ageing populations, non-communicable diseases are the driver for change. The pioneering paper on the epidemiology of such disease was funded by the Medical Research Council and published by Richard Doll in 1950. He linked smoking behaviour to lung cancer. Doll then found "most cancer research workers did not accept it, and in fact they advised the Department of Health that they shouldn't take any action because they were uncertain about what it meant" (Doll, 2004). However, the key event for public perception was the death in 1952 of a heavy smoker, King George VI, from a combination of lung cancer and coronary heart disease. Doll (2004) observed "it wasn"t until 1957, when the Government asked the MRC for a formal opinion as to whether our conclusion was correct or not, that the MRC formally considered it and said it was correct and advised the Government to that effect. The result was that the Minister of Health in 1957 called a press conference to announce the results of the MRC consultation. He announced that the MRC had advised them that smoking was the cause of the great increase in lung cancer".
Perceptions of healthy aging have been informed by longitudinal research that followed cohorts of people prospectively over time, looking for factors that predicted "good" or "bad" health outcomes. Death and disability are associated in particular with non-communicable disease, and the most common pattern of unhealthy aging involves the accumulation of more and more disorders with age. A famous study that began in 1938 has followed 268 Harvard students until the present day, when the survivors are in their 90s. The progress of this small but incredibly data-rich research has been detailed by George Vaillant (2012). By the time the Harvard graduates were aged 70, it was clear that the key health risk factors had been present much earlier. For example heavy drinking between the ages of 40 and 50 years increased the risk of disability, decades later.
Before the age of 50, these seven factors impact on later health (between 70 and 80 years) and suggest areas for intervention:
body mass index;
coping mechanisms; and
education (Vaillant and Mukamal, 2001).
Larger than the Harvard sample, the UK's 1946 Birth Cohort includes both men and women, who have been followed into their 60s. At age 43, eating well and keeping physically active reduces the risk of cognitive decline over the next 20 years (Cadar et al., 2012). In this Special Issue, Breeze reviews the lessons about degenerative changes in the brain, from 158 cohort studies.
The World Health Organisation suggested the four main behavioural risk factors for non-communicable diseases are smoking status, alcohol consumption, physical inactivity and poor diet (e.g. no consumption of fruit). In a Swiss sample of over 16,000 people Martin-Diener et al. (2014) found that 75-year-old men with none of these four behavioural risk factors had the same probability of surviving the next ten years as those men who were still ten years younger but had all four risk factors. Norton et al. (2014) have sought to calculate the population-attributable risk of Alzheimer's disease for seven risk factors, of which the largest effect found was for Education. Identifying such modifiable risk factors long before dementia appears, opens the way to primary prevention of this illness in the future.
Society ignores and then accepts
A slow fade to grey, and black.
But the settings of the human mind
Are set a long, long way back.
While Politics sees only "strivers", "skivers",
Middle age is time to act:
Stimulate resilience of our minds
As lifelong learners, livers.
Cadar, D., Pikhart, H., Mishra, G., Stephen, A., Kuh, D. and Richards, M. (2012), "The role of lifestyle behaviors on 20-year cognitive decline", Journal of Aging Research, available at: http://dx.doi.org/10.1155/2012/304014 (accessed 23 July 2014).
Doll, R. (2004), ""Science will always win in the end", Interview by Wagstaff, A." Cancer World, No. 3 December, pp. 28-34
Martin-Diener, E., Meyer, J., Braun, J., Tarnutzer, S., Faeh, D., Rohrmann, S. and Martin, B.W. (2014), "The combined effect on survival of four main behavioural risk factors for non-communicable diseases", Preventive Medicine, Vol. 65, August, pp. 148-152
Norton, S., Matthews, F.E., Barnes, D.E., Yaffe, K. and Brayne, C. (2014), "Potential for primary prevention of Alzheimer's disease: an analysis of population-based data", Lancet Neurology, Vol. 13 No. 8, pp. 788-794
Vaillant, G.E. (2012), Triumphs of Experience: The Men of the Harvard Grant Study, Harvard University Press, Cambridge, MA
Vaillant, G.E. and Mukamal, K. (2001), "Successful aging", American Journal of Psychiatry, Vol. 158 No. 6, pp. 839-847