Humans are living longer than ever. However, with longer lifespans comes an increased risk of age-related conditions, including dementia. Dementia is one of the greatest challenges world-wide, in terms of the number of people affected and the required resources. In the USA alone, around 5.2 million people are currently living with dementia.
Dementia is a syndrome characterised by a deterioration in cognitive ability, thought processes, and behaviour. Behavioural symptoms of dementia (BSD) include sleep disturbances, agitation, hallucinations, extreme emotions, wandering, and resistance to care. Dementia is one of the major causes of disability and dependency amongst older adults, and it can have a substantial physical, psychological, and social impact on individuals living with the condition, and those around them. Dementia also has a substantial economic impact: it cost the US economy around $236 billion this year.
Dementia rates differ among various ethnic groups, and one size does not fit all when it comes to interventions for behavioural symptoms of dementia. For example, Latinos are 1.5 times more likely to have Alzheimer’s Disease than Caucasians, and some treatments that are effective for Caucasians may not be effective for Latinos. However, the best way to treat the behavioural symptoms of dementia in ethnic and racial minority groups is not yet fully understood.
To address this, Dr Diana Lynn Woods from Azusa Pacific University researches ways to deliver culturally appropriate treatments to older Latinos with dementia. Dr Woods’ research explores the current ways that BSDs are assessed and treated in Latino populations, in addition to the role of genetic and environmental factors in prescribing medications to Latinos with BSD. A further aspect of Dr Woods’ work investigates the effectiveness of non-pharmacological approaches for BSD, which include the integration of ethnocultural and traditional healing systems into existing Western non-pharmacological approaches.
Cultural factors of behavioural symptoms of dementia
Ethnic minorities are often underrepresented in dementia research, and so our understanding about ethnic differences in the symptoms and treatments of dementia remains limited. Future dementia research must include ethnic minority individuals to help us understand the similarities and differences in BSD across different ethnic groups.
Compared to White populations, Hispanic individuals often receive a diagnosis at a much later stage of dementia and thus may have an increased risk of exhibiting behavioural symptoms of dementia. Cultural factors can influence the interpretation and recognition of behavioural symptoms of dementia. For example, since younger people are expected to show high levels of respect for their elders, the acknowledgement of changes in cognition and/or behaviour is often delayed. Indeed, Dr Woods’ notes previous research that showed 65% of Hispanic caregivers dismissed symptoms of dementia due to the belief that it is a normal part of ageing.
In the USA alone, around 5.2 million people are currently living with dementia.
Moreover, on relocating to the United States, many minority ethnic groups choose to retain their traditional healing practices. Traditional healing approaches to dementia often incorporate spiritual beliefs, such as the illness being caused by being bewitched, and focus on restoring balance in the spiritual realm. Caregivers in the Latino community often seek help from traditional healers alongside clinical healthcare professionals. Therefore, to effectively manage BSD in Latino populations, it is critical for healthcare providers to enquire and become knowledgeable about the traditional healing methods of Latino groups. Interestingly, positive outcomes have been shown when healthcare providers use an inclusive approach to healing in clinical settings.
A range of pharmacological and non-pharmacological interventions are available to treat BSD. However, assessment of any behavioural symptoms and behavioural change is vital before BSD symptoms are treated.
In terms of pharmacological interventions, the class of medications used for treating BSD is psychotropic medications, which includes antipsychotics, antidepressants, and sedative hypnotics. Dr Woods argues that pharmacological interventions are often over-used, or used inappropriately, and can therefore be ineffective for people with BSD. Some evidence even suggests that psychotropic medications can have a detrimental effect on individuals. Of those taking psychotropic medications, 30% are associated with a high risk of mortality.
Indeed, there tends to be an assumption of universality in prescribing practices of medication for BSD, largely influenced by the dominant Caucasian population in whom the drugs were tested.
Cultural or ethnic factors may influence an individual’s response to medication and indeed evidence shows significant differences in response to psychotropic drugs in different ethnic groups This field of research, known as ‘ethnopharmacology,’ explores the ways in which genetic differences between ethnic populations can influence the ways in which drugs are absorbed and excreted, plus their mechanisms of action. It is essential that the genetic variation of these enzymes be considered in Latinos when implementing pharmacological treatments since they have a significant effect on the timing of medications and the dosage for optimal therapeutic effect.
The Use of Psychotropics and Role of Genetic Variation
Psychotropic drugs, while commonly used to manage behavioural disturbances in people with dementia, are not recommended as the first line of treatment because of the significant side effects. The outcomes of psychotropic medications are often less effective than hoped for. Several factors can impact upon the efficacy of these medications, such as pre-existing medical conditions, age, and ethnicity. For example, there is a lack of evidence to suggest that psychotropic drugs are effective in older Latino adults. Genetic differences also play a significant role in the effectiveness of psychotropic medication for dementia and the same drug can be metabolised differently, depending on the individual’s genetic profile. Dr Woods argues that dementia outcomes are much improved if genetic factors are considered when prescribing medications.
To complicate matters further, interactions among genes, environment, and culture also can influence an individual’s response to psychotropic medication. Environmental factors such as diet, air pollution, herbal supplements, and tobacco smoking play a significant role in the absorption, metabolism, distribution, and elimination of psychotropic medication. These environmental factors modify the way in which genes are expressed i.e., they have an epigenetic effect. For example, tobacco smoking, which is common in some Latino cultures, can have a profound influence on effectiveness of several psychotropic drugs. Much more work is needed to fully understand gene-environment interactions in Latinos, particularly regarding psychotropic medications.
Much more work needs to be done to fully understand gene-environment interactions in Latinos, particularly with regards to psychotropic medications.
Given the varied effectiveness of psychotropic medications, the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults recommends that psychotropics should be used with caution for dementia and should only be prescribed if non-pharmacological interventions have been unsuccessful. Dr Woods recommends further research is needed to examine responses to psychotropic medications across different ethnic groups. She also proposes that healthcare professionals be informed about the risks of prescribing psychotropics to individuals of different ethnic groups and informed about the various non-pharmacological approaches to treating dementia.
Non-pharmacological interventions are recommended as first line treatments for dementia care. Non-pharmacological interventions for dementia can include cognitive/emotion-oriented interventions (e.g., reminiscence therapy), sensory stimulation (e.g., aromatherapy; massage/touch therapy), and other psychosocial interventions (e.g., animal assisted therapy). Those with a sensory focus show more promise than others.
There have been several advances in research into non-pharmacological interventions, although there is currently no consensus about how to categorise these interventions or make evidence-based recommendations for their use. There have been several hundred small clinical trials which have shown promising results to suggest that non-pharmacological interventions have potential benefits for individuals with dementia and their caregivers. However, many of these studies have methodological issues which hamper our understanding of the effectiveness of non-pharmacological interventions. Future research using large-scale clinical trials is therefore needed to better understand the effectiveness of non-pharmacological interventions in dementia. Individuals from different ethnic groups must be included in future research, to understand whether there is variation in responses to specific non-pharmacological interventions.
Dr Woods’ research suggests that an interdisciplinary team approach has the best chance of success, drawing on a variety of knowledge areas and offering an integrated intervention.
Overall, Dr Woods’ research highlights the need for additional interdisciplinary research into BSD, specifically within the Latino population. She asserts the importance of healthcare providers acquiring knowledge about traditional healing practices that many Hispanic/Latinos use and working with healers to achieve positive treatment outcomes. Dr Woods recommends that psychotropic medications are used with extreme caution due to the many negative side effects. As for non-pharmacological interventions, further research is needed so that current recommendations can be implemented.
How can we ensure that Latino populations are included in clinical research trials?