(26)抑郁和认知症风险-Depression and Dementia Risk-公开课-关爱惟士
(26)抑郁和认知症风险-Depression and Dementia Risk

课程视频:http://player.youku.com/embed/XMjY3ODM3ODMyMA



Text Overview of Video

Professor Nicola Lautenschlager

Nicola Lautenschlager教授


When we look at common risk factors for cognitive decline and dementia, depression is one of the most prominent ones. One interesting question is, “Why is that the case?” and, “What do we know about this?” One observation is that, especially if people have had several significant episodes of clinical depression throughout their lifetime, that it looks like there is an accumulative risk of depression, in terms of their cognitive health, when they get older. There are some underlying strong hypotheses, which one comes across in the literature, about why increasing numbers of depressive episodes throughout life might increase the risk of dementia later on. One of these hypotheses is that it has to do with the impact of having increased stress hormones in your body, while you go through a depressive episode. For example, one of these stress hormones is cortisol, and we do know that if you have, for a prolonged period, high levels of cortisol in your body, as is the case when you have a depression, it specifically damages the neurons in the hippocampus, which we know we need to lay down new memory, and which is the area which is damaged early in Alzheimer's disease. Therefore, the message for consumers and clinicians is, if depression is present at any time in life, it’s important to diagnose it as early as possible, and to treat it effectively, as early as possible, to reduce the time with having high hormonal stress burden on the brain. It is more the untreated, unrecognised depression which is harmful for future dementia risk, and not so much the well treated depression, if that makes sense.

当我们研究认知衰退和痴呆的常见风险因素时,抑郁症是最突出的一个。一个有趣的问题是,“为什么是这种情况?”和“我们知道什么?”一个观察是,如果人们在他们的一生中有几个重大的临床抑郁症的发作,看起来特别像是抑郁症在认知健康方面的风险累积。在文献中有一些潜在的强有力的假设,其中有一个是关于为什么越来越多的抑郁发作在整个生活中可能会增加后来患认知症的风险的假设,你经历一个抑郁发作,它与你的身体里的压力激素增加的影响有关。例如,其中一种压力激素是皮质醇,据我们所知如果当你抑郁症发作后,你在你的身体中会长期有高水平的皮质醇,,它会专门损害在海马区的神经元。我们知道我们需要把新的记忆储存在海马区,这是在阿尔茨海默病早期损坏的区域。因此,消费者和临床医生的信息是,如果抑郁症存在于生命中的任何时间,重要的是尽早诊断它,并且尽可能早地进行有效的治疗,以减少大脑的高激素压力负担的时间。未治疗的,未被识别的抑郁症,对未来的认知症风险更有害,而不是治疗好的抑郁症,如果这是有道理话的。


Another interesting fact is that depression and dementia share many risk factors, and they’re both common. Obviously, an interesting research question is, “How much are they connected, and how much is just the fact that they share common risk factors?” I’ll give you an example. It has been shown that early experience of trauma in childhood, which might be physical, sexual or psychological, is harmful for having a higher risk later on of developing depression. But more recently, it has also been shown that it is a risk factor independently for having a high risk of dementia. That’s just one example. If you look at chronic health conditions, we know that especially cerebrovascular disease or vascular risk factors, like chronic heart disease, chronic hypertension, anything which basically damages the blood vessels and subsequently also the blood vessels in the brain, increases the risk of having depression, but also increases the risk of having cognitive decline. There is actually a specific term for older people, when they experience depression in the presence of many vascular risk factors, which we call “vascular depression.”

另一个有趣的事实是抑郁症和认知症共同有许多危险因素,而且这些因素都很常见。显然一个有趣的研究问题是,“他们有多少联系,他们有多少共同的风险因素?”我给你举一个例子。已有研究表明儿童期创伤的早期经验,这可能是身体,性或心理上的,是有害的,这对后来发展成抑郁症具有更高的风险。但是最近的研究已表明,它是独立地具有高痴呆风险的风险因素。这只是一个例子。如果你看看慢性健康状况,我们知道特别是脑血管疾病或血管危险因素,如慢性心脏病,慢性高血压,基本上任何损害血管以及随后伤害脑血管的东西,都会增加抑郁的风险,但也增加了认知衰退的风险。实际上,对于老年人,当他们在有许多血管风险因素时经历抑郁症时, 我们称之为“血管性抑郁症”这一特定的术语。


When it comes to treatment of depression in older people, the take-home message is, it should be treated as aggressively in older people as it is treated in younger people. There is no room for therapeutic nihilism just because a person is older. The good news is that older people very often respond very well to appropriate treatment which, for most people, would be a combination of social support and psychological support, plus use of anti-depressants, and usually general practice is the area where this treatment takes place. Basically, depression is one of the best treatable mental health conditions we have. There are some differences between young and older people. Because of the presence of chronic health problems, there is a percentage of older people with depression who have a poorer outcome in terms of recovery. Meaning they might have more, what we call, treatment resistant depression, or might not be able to be completely free of symptoms. They also can have a higher risk of relapse. So the recommendation is, if they benefited well from an anti-depressant, they should stay on that medication and not stop again, to avoid the higher relapse risk.

当谈到老年抑郁症的治疗时,我们应该像治疗年轻人一样去积极地治疗老年人。没有只因为一个人年纪大了而存在治疗虚无主义的空间。好消息是,老年人往往对恰当的治疗反应很好,对于大多数人来说,恰当的治疗将是社会支持和心理支持的组合,加上使用抗抑郁药, GP通常是这种治疗的地点。抑郁症基本上是我们拥有最好治疗效果的精神卫生疾病之一。年轻人和老年人的情况有些不同。由于存在慢性健康问题,有一定比例的抑郁症老年患者,在恢复方面有较差的结果。这意味着他们可能有更多的我们所说的治疗耐药性抑郁症,或者可能无法完全没有症状。他们也可能有更高的复发风险。因此,我们的建议是,如果他们从抗抑郁剂中获益良好,他们应该坚持服用那种药物,不再停药,以避免更高的复发风险。


A common myth is that older people are less able to benefit from psychotherapy. This goes all the way back to Sigmund Freud, who stated that himself, that if a person is older than 50 years they are too old and rigid to benefit from psychotherapy. It’s quite amusing because when he got older himself and was in his eighties, he actually reversed this statement and said it’s not true, but by that stage people were not listening to it anymore. So older people should be offered psychotherapy, if appropriate. And it has been shown, in research studies, that people who are psychologically-minded benefit very well from, for example, cognitive behavioural therapy, even if they’re older. What is a challenge in the health system in Australia, is that very often, there is a lack of therapists who are specialising in older people with mental health problems.

一个常见的神话是,老年人较少能够从心理治疗中受益。这一切都回到了西格蒙德·弗洛伊德时代,他说如果一个人年龄大于50岁,他们就太老了,内心僵硬得无法受益于心理治疗。这是很有趣的,因为当他年龄增长,在他八十多岁时,他实际上扭转了这个声明,并说,这不是真的,但在那个阶段,人们没有听到他的声明了。因此,如果合适的话,老年人应该得到心理治疗。并且相关研究已表明,老年人也能从例如认知行为治疗中获益良好。经常缺乏专门解决老年精神健康问题的治疗师。

是澳大利亚卫生系统的一个挑战。


One important message is that older people with depression should receive adequate treatment and there are regular mistakes happening in this field. One common mistake is that healthcare providers give a too low dose of an anti-depressant, for example, because they are anxious it could have negative side effects. On one hand, obviously it’s important to be careful and older people often do need lower doses, but we see in clinical practice that very often the dosage is not increased to an adequate level, or not given long enough, and then often it’s wrongly concluded that the medication is not working. It’s really important to treat long enough, with the right medication, at the right dosage. This is also important because the longer the older person lives with clinically relevant depression, the more it increases the risk that their cognition is impacted negatively and it increases their risk of dementia.

一个重要的信息是,老年抑郁症患者应该得到充分的治疗,这是在这个领域常犯的错误。一个常见的错误是,医疗保健提供者给予过低剂量的抗抑郁剂,例如,因为他们担心它可能有副作用。一方面,显然重要的是要小心,因为老年人通常需要较低的剂量,但我们在临床实践中看到,剂量通常不会增加到足够的水平,或用药时间不够长,然后往往错误地得出药物不起作用的结论。选择合适的药物、使用正确的剂量、进行足够长时间的治疗,这是非常重要。这也很重要,因为老年人患临床相关抑郁症的时间越长,他们的认知受到负面影响的风险就越高,从而增加了他们患认知症的风险。


Another important aspect is how our society thinks about ageing. An argument you hear quite often, for example, from nursing homes is, “Oh yes, if I lived like this person, I would be depressed as well.” So it’s normal for this person to be depressed, so we don’t need to treat it. As a society we need to work on that we all change these attitudes, and say an older person is as much entitled to the best possible healthcare as a younger person, and that this is really a sign of ageism, if we conclude, as younger people, that it’s not worth the effort, or that it’s normal for an older person to suffer.

另一个重要的方面是我们的社会如何看待老龄化。例如,从养老院听到的一个谈论是,“哦,是的,如果我像这个人一样生活,我也会抑郁。”所以这个人会郁闷是正常的,所以我们不需要治疗它。作为一个社会,我们需要努力改变这些态度,并说,老年人尽可能有权活得像年轻人一样的最好的医疗保健服务。如果我们得出结论,对老年人像对年轻人的那样的努力是不值得,或一个老年人受苦是正常的,这是真正的年龄歧视的迹象。


Depression as a symptom is one of the most common non-cognitive symptoms of dementia. People who have dementia, for whatever cause or reason, have a much higher risk of experiencing symptoms of depression than an older person who does not have dementia. Screening for, and detecting, depression in patients who experience dementia, is very important as, again, it has very poor outcomes for them, if the depression is not recognised. There are quite interesting studies that report very high numbers of depression in, for example, residential care.

作为症状的话,抑郁症是认知症的最常见的非认知症状之一。无论什么原因,认知症的老年患者比没有认知症的老年人具有更高的经历抑郁症状的风险。筛查和检测认知症患者是否经历抑郁症的是非常重要的,因为如果抑郁症不被识别,结果会很差。有相当有趣的研究报告了非常多的抑郁症,例如,住院护理。


Interestingly, when it comes to treatment of depression in people with dementia, more recent research has shown that, unfortunately, the currently available anti-depressant medication is less effective, for example, in people with Alzheimer's disease and, furthermore, that people with dementia often have a higher risk of experiencing negative side effects of the medication. It is important to take that into account when a treatment plan is put together. However, the current recommendation is still, if a person is significantly depressed with dementia, medical treatment with an anti-depressant should be considered. If the depression is rather of a milder nature, then the recommendation is maybe not to use anti-depressants as a first line treatment, but rather try non-pharmacological approaches. So that could mean increasing pleasant activities, making sure the person’s not isolated, increasing social contact, increasing physical activity, nutrition and diet and all these things, and see if that already makes a good impact.

有趣的是,当涉及到认知症患者的抑郁症的治疗时,最近的研究表明不幸的是目前可用的抗抑郁药物在像阿尔茨海默病患者中效果较差,此外,认知症患者通常具有经历药物副作用的较高风险。当治疗计划放在一起时,必须考虑到这一点。然而,目前的建议仍然是,如果一个认知症患者的抑郁症显著,应该考虑使用抗抑郁药物的治疗。如果是轻微的抑郁症,那么可能推荐不使用抗抑郁剂作为一线治疗,而是去尝试非药物的方法。所以这可能意味着增加愉快的活动,确保不被孤立,增加社交联系,增加体育活动,注意营养和饮食和所有这些事情,并看看是否已经产生了良好的效果。


A rather new, but very important field of research, is investigating what we can do to prevent the onset of depression in the first place. So if we could think of a health care system where we reduce, from the outset, the risk for an older person to experience late-onset depression, that would be perfect. The knowledge in this area is still very limited. Again, there is some interesting research highlighting that prevention of depression might be possible, and factors to think about and look at more closely are the social environment of an older person, trying to avoid that the person is isolated or feels disconnected from their community, feels they’re a burden, or can’t actively contribute any more to society, would be important. But equally, to look at their physical health, to manage optimally chronic disease, as it is a strong risk factor for depression. Other areas are, for example, hearing loss and loss of vision, which both are strong risk factors for depression in older people, to screen for that regularly. So it looks like there are quite a number of things we can do as a society to reduce, in general, the onset of depression, and that subsequently obviously also help to reduce the onset of cognitive impairment and dementia.

一个相当新的,但非常重要的研究领域,是调查我们可以做些什么来预防抑郁症的发生。因此如果我们能想到一个能从一开始就减少老年人经历迟发性抑郁症的风险的医疗保健系统,这将是完美的。这方面的知识仍然非常有限。其次,有一些有趣的研究强调,预防抑郁症的或许是可能的,并且需要考虑和更仔细地看待的因素是老年人的社会环境。努力避免他们被隔离或感觉与他们的社区分离,避免让他们感觉自己是负担或不能积极地贡献社会,这些是很重要的。但同样,检查他们身体是否健康,以便理想地管理慢性疾病,因为这是抑郁症的一个强大的风险因素。其他领域是,例如,定期筛查听力损失和视力丧失,这两者都是老年人抑郁症的强烈风险因素。所以看起来,作为一个社会,我们可以做许多事情,一般来说减少抑郁症的发病,显然随后也有助于减少认知损伤和患认知症。


翻译:关爱惟士-未经允许不得转载,违者必追究法律责任

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