Are Population-Level Approaches to Dementia Risk Reduction Under-Researched? A Rapid Review of the Dementia Prevention Literature

Dementia is forecast to become increasingly prevalent, particularly in low- and middle-income countries, and is associated with high human and economic costs. Primary prevention of dementia -preventing risk factors leading to disease development - is an emerging global public health priority. Primary prevention can be achieved in two ways: individual-level or population-level. In this rapid review, we quantify the proportion of contributing interventional evidence to the dementia primary prevention literature that is concerned with either approach. We searched Medline, the National Institute for Health and Care Excellence, Cochrane, the World Health Organization, and Google to identify systematic reviews that described primary prevention interventions for dementia. We used search terms related to dementia risk reduction, intervention/policy, and review. We analysed reference lists of included dementia prevention reviews to identify contributing primary prevention evidence, and categorised these as either individual-level or population-level. Additionally, we examined search strategies to investigate the likelihood of reviews identifying available population-level interventions. We included twelve of the 527 articles retrieved. Population-level evidence was summarised by only two reviews. In these two reviews, <2.5% of the interventions described where population-level interventions. Most search strategies were weighted towards identifying individual-level evidence. Existing systematic reviews of dementia primary prevention interventions include almost no population-level evidence. Correction of this imbalance is needed to ensure that dementia prevention policies can achieve meaningful reductions in the prevalence of, and inequalities in, dementia.

What is a population-level approach to prevention, and how could we apply it to dementia risk reduction?

The World Health Organisation's 2022 'blueprint for dementia research' highlights the need for more research into population-level risk reduction. However, definitions of population-level prevention vary, and application to dementia is challenging because of its multi-factorial aetiology and a maturing prevention evidence base. This paper compares and contrasts key concepts of 'population-level prevention' from the literature, explores related theoretical models and policy frameworks, and applies this to dementia risk reduction. We reach a proposed definition of population-level risk reduction of dementia, which focusses on the need to change societal conditions such that the population is less likely to develop modifiable risk factors known to be associated with dementia, without the need for high-agency behaviour change by individuals. This definition, alongside identified policy frameworks, can inform synthesis of existing evidence and help to co-ordinate the generation of new evidence.

Psychiatric liaison service referral patterns during the UK COVID-19 pandemic: An observational study

BACKGROUND AND OBJECTIVES

COVID-19 has had a profound effect on mental health. Liaison psychiatry teams assess and treat people in mental health crises in emergency departments (EDs) and on hospital wards. During the first pandemic wave, new Mental Health Crisis Assessment Services (MHCAS) were created to divert people away from EDs. Our objective was to describe patterns in referrals to psychiatric liaison services across the North Central London care sector (NCL) and explore the impact of a new MHCAS.

METHODS

Retrospective study using routinely collected data (ED and ward referrals) from five liaison psychiatry services across NCL (total population 1.5 million people). We described referrals (per week and month) by individual liaison services and cross-sector, and patterns of activity (January 1st 2020 -September 31st 2020, weeks 1-39) compared with the same period in 2019. We calculated changes in the proportion of ED attendees (all-cause) referred to liaison psychiatry.

RESULTS

From 2019-2020, total referrals decreased by 16.5% (12,265 to 10,247), a 16.4% decrease in ED referrals (9528 to 7965) and 16.6% decrease in ward referrals (2737 to 2282). There was a marked decrease in referrals during the first pandemic wave (March/April 2020), which increased after lockdown ended. The proportion of ED attendees referred to liaison psychiatry services increased compared to 2019.

CONCLUSIONS

People in mental health crisis continued to seek help via ED/MHCAS and a higher proportion of people attending ED were referred to liaison psychiatry services just after the first pandemic wave. MHCAS absorbed some sector ED activity during the pandemic.

The social invisibility of mental health: understanding social exclusion through place & space

Background

The European target that the 5% of the healthcare service budget goes to mental health might not be enough to cover the inequity between health and mental health provision. The project is a multi-disciplinary, research-through-arts project, involving a Faculty of the Built Environment, a Division of Psychiatry and a School of Art. The project aims to identify elements demonstrating inequality demonstrated from place and space related to the facility provision.

Methods

The research compares mental vs healthcare facilities inside a catchment area, with photographs of the facades of the buildings and mapping their proximity to public transportation. It juxtaposes mental/healthcare facilities for access, condition and status compared to their surroundings.

Results

A book and an exhibition close to Bentham’s auto-icon, the designer of Panopticon custodial facility, demonstrated inverse links between his Panopticon, and the invisibility that NIMBYism produces towards the mentally ill that resulted in their exclusion, within deprived, vandalized, under-funded, isolated from public transport facilities “in the community”.

Conclusions

The project identified factors that contribute to the isolation of mental health facilities in terms of both space and place, and set the basis for further research in future projects. It demonstrated visually the under-budgeting of mental health facilities and their stigmatization as expressed by the centrality of locations and their overall projected image. This outlined the path for integrated, transdisciplinary research in the future involving architecture, arts and psychiatry. The project increased the awareness of the general public on social injustice, stigma and mental health. It combats NIMBYism and supports the fairer allocation of resources and placement of health facilities, aiming to put pressure to stakeholders involved in the NHS decision. Actions have been taken by the Trust involved to change.

Key messages

Inequalities between building (facades and location) contribute to mental illness stigma: this is what the general public views daily. Architecture can be a powerful medium to support inclusion.