I recently delivered a short lecture on risk for dementia resulting from depression or loneliness. The research evidence is strong that a history of depression, and the severity of symptoms both in early and late-life depression does convey a risk. The evidence is also strong that an association exists between one’s perceived sense of loneliness and a risk or perhaps a vulnerability for dementia. Across studies, loneliness and/or depression is hypothesized to be either a consequence of cognitive decline and is perhaps a behavioral reaction to diminished cognition. Or it may be that loneliness or depression compromises the neural systems essential to cognition and memory suggesting that the neural pathways underlying social behavior become less elaborated or flexible.
Clearly, we have the proverbial chicken or the egg question. So rather than try to find absolutes I have come to think about this as a dynamic, reciprocal relationship very much in keeping with the bio-psycho-social model of social work practice. As a social worker, I am trained to be an observer of behavior and not to think linearly. I have developed a mental image of a series of intersecting cogs of a wheel – constantly in motion –or the continuous looping around of multiple variables that can affect a person’s life.
In this group of journal articles*, I was introduced to the concepts of socio-cognitive skills and Mild Behavioral Impairment (MBI). To appreciate the idea of MBI, you have to first look at what makes up a person’s social environment which would include the size of the social network, the frequency of contacts, and the quality and complexity of social relationships. The intention of understanding social network is to understand an individual’s perceived loneliness which was scored using a Loneliness Scale**. Rather than simply asking about the number of family visits or marriage status, these scales give richness to the discussion of loneliness and helps describe quality of life. You can have many contacts, but still feel alone. Or conversely you can have a few contacts and not feel alone at all and feel good about those people with whom you do have a relationship. And so, one of the research studies found that feeling lonely rather than being alone was associated with dementia onset suggesting that it is not the objective situation, but the perceived absence of social attachments that increases risk, though – and importantly – it is not predictive. (Holwerda, et al)
It takes a fair number of skills to effectively navigate the social environment. These socio-cognitive skills include the capacity to understand emotions in self and others; to decode facial expressions and non-verbal communication; the ability to interpret people’s desires and intention; the ability to regulate behavior and be flexible in social interactions (isn’t it interesting how similar these are to describing a young child on the autism spectrum?) If a person didn’t have these social skills as a result of being in the early stages of dementia, mightn’t we see behavioral change — what we might have called personality change 20 years ago? Some researchers have begun to call this Mild Behavioral Impairment defined by these features
- apathy/lack of drive or motivation;
- mood lability or lack of affect; possible anxiety;
- lack of impulse control and occasional agitation and
- instances of social inappropriateness.
As keen observers that social workers are, being able to recognize these behaviors and describe and discuss with family members seems awfully powerful to me. For me it speaks to possible markers for early detection and critically, to be able to have meaningful conversations.
*JOURNAL ARTICLES USED FOR THIS DISCUSSION
- Becker, James T. et al, Depressed Mood is not a Risk Factor for Incident Dementia in a Community- Based Co-hort, American Journal of Geriatric Psychiatry, 2009 August; 17 (8); 653-663.
- Byers, Amy L. and Yaffe, Kristine, Depression and Risk of Developing Dementia, , Nature Reviews: Neurology, Volume 7, Jun 2011, 323-331.
- Gow, Alan J., et al ,Which Social Network or Support Factors Are Associated with Cognitive Abilities in Old Ag , Behavioural Science Section, Gerontology 2013; 59: 454-463.
- Holwerda, Tjalling Jan, et al, Feelings of Loneliness, But not Social Isolation Predict Dementia Onset, Journal of Neurology and Neurosurgical Psychiatry, 2014;85: 135-142.
- Jorm, A.F., Is Depression a Risk factor for Dementia or Cognitive Decline? A Review, Gerontology Behavioural Science Section, Gerontology 2000; 46: 219-227
- Kim, Kye Y. and Detweiler, Mark B., Apathy in Persons with Alzheimer’s Disease: An Overview, Alzheimer’s Care Today 2010; 11(4); 251-259.
- Melville, Nancy A., Loneliness Linked to Alzheimer’s Disease, Medscape.com; November 07, 2016.
- Panza, Francesco, et al, Late-Life Depression, Mild Cognitive Impairment, and Dementia: Possible Continuum? American Journal Geriatric Psychiatry 18:2 February 2010 98-116.
- Wilson, Robert S., et al, Loneliness and Risk of Alzheimer Disease, Archives of General Psychiatry, 2007;64:234-240.
**THE UCLA LONELINESS SCALE
**THE deJONG LONELINESS SCALE