Discussion Of The Potential Psychosocial Impact Of Alzheimer’s Disease

Neurological disorders can put a deep strain on the patients affected, their families, carers and the NHS. One of the most common neurodegenerative disorders amongst older people in the UK is Alzheimer’s disease (AD) which is the leading cause of dementia, and for which there is currently no cure. There are many devastating consequences of AD, including comorbidity with depression, caregiver burden, economic concerns and social exclusion. With such wide-ranging and detrimental psychosocial impacts, it’s important to find ways of reducing their influence. This would not only improve the quality of life (QoL) of Alzheimer’s patients but would also aid a less stressful environment for them and their families. This essay will discuss some of the prominent psychosocial impacts of AD and will explore how these impacts are and can be moderated.

AD is characterised as a physical disease in which neuronal connections cease to function resulting in the death of nerve cells and loss of brain tissue (Alzheimer’s Association, 2016). Subsequently, this leads to significant cognitive impairments which can cause problems in daily life. These include memory loss, confusion, difficulty with completing familiar tasks, linguistic issues and poor judgement (Palmer et al., 2007). As a result of such debilitating impairments, many AD patients also experience depression. The comorbidity rate of AD and depression in the UK is extremely high, with up to 50% of AD patients being diagnosed with depression or clinically significant depressive symptoms (Starkstein, Jorge, Mizrahi & Robinson, 2005). This highlights that one of the biggest psychological impacts of AD can be the deterioration of mental health. Particularly, depression can affect overall outcomes and decrease the QoL of Alzheimer’s patients (Orgeta, Tabet, Nilforooshan & Howard, 2017). Therefore, not only do the majority of AD patients have to deal with the cognitive deficits associated with their ailment, but also the psychological toll of depression, which can further decrease their QoL and bring about additional symptoms that need to be addressed.

The most widely used treatment for depression in both depressive and AD patients is antidepressants, including sertraline and fluoxetine (Cabalerro, Hitchcock, Beversdorf, Scharre & Nahata, 2006). The use of antidepressants in AD patients is driven by a lack of alternative treatment options and the view that antidepressants are effective in this population (Kessing, Harhoff & Andersen, 2007). However, several randomised control trials have found conflicting results when it comes to the efficacy of antidepressants, as compared with placebos (Magai, Kennedy, Cohen & Gomberg, 2000; Petracca, Chemerinski & Starkstein, 2001; Lyketsos et al., 2003). Moreover, the use of antidepressants in AD patients is associated with significant side effects, including hyponatremia (De Picker, Van Den Eede, Dumont, Moorkens & Sabbe, 2014), cardiotoxicity (Sultana, Spina & Trifirò, 2015) and increased bleeding tendency (Jasiak & Bostwick, 2014; Gahr et al., 2015). Not only do these side effects present physical symptoms but they can further increase stress and worry amongst AD patients who experience them (Porter et al., 2003). Therefore, antidepressants may not be the most ideal treatment for depression in this population.

An alternative to antidepressants that could be of particular interest is resilience enhancers. The recent work of Brachman et al. (2016) has shown how prophylactic ketamine can protect against the effects of stress-induced depressive symptoms by increasing resilience to stressful situations in mice. Whilst research thus far has looked primarily at mice and is still in early stages of development, this could provide a prevention method for people prone to stress-induced depression – including AD patients. This means that upon diagnosis of AD, patients could be prescribed these resilience enhancing drugs to prevent them from developing depression. This has the potential to increase both outcomes and QoL in Alzheimer’s patients, which would reduce, if not eradicate, the psychological impact of depression.

Since many Alzheimer’s patients often need long-term care (Alzheimer’s Association, 2015), it is also important to moderate the influences caregiving can have on the families and spouses of patients. One of the prevalent psychosocial impacts of AD is caregiver burden and distress. This can result in severe fatigue, difficulty maintaining personal relationships and struggling to combine caring with other commitments (Adelman, Tmanova, Delgado, Dion & Lachs, 2014). With such demands on the caregiver, this can have the direct effect of hindering the quality of care administered. Additionally, becoming a caregiver can cause a major financial strain as caregivers often have to reduce their working hours outside the home or leave their jobs (Tilden, Tolle, Drach & Perrin, 2004). Unfortunately, caregivers are not always compensated for their time, as to obtain carers allowance in the UK several criteria must be met, meaning those who do not meet all of the criteria will not be eligible (Carmichael, Hulme, Sheppard & Connell, 2008). This coupled with the burden and distress associated with constant care can ultimately lead to depression and low QoL for the caregiver.

One method of reducing caregiver burden is to reduce the symptoms of AD patients so that less care is needed. This can be done by prescribing donepezil to AD patients. This not only has the benefit of partially increasing mental function and ability to function in AD patients (Evans, Ellis, Watson & Chowdhury, 2000), but decreased symptomology is also associated with less caregiving time and lower levels of caregiver stress as measure by subjective burden (Baronet, 1999). Not only can this aid the patient, since lower severity of AD symptoms is associated with decreased depressive symptoms (Lyketsos et al., 1997), but this can create a less stressful environment for both patient and caregiver. This results in a higher QoL for both (Feldman et al., 2003), and is more conducive to aiding the management of symptoms.

Additionally, Carers UK (2017) argues that improved funding for social care can also assist in lowering caregiver burden, for example by providing more formal support for carers as well as the people they care for. This includes counselling, support groups and respite care, all of which have positive influences on the psychological well-being of carers (Gallagher-Thompson & Coon, 2007). Furthermore, raising Carer’s Allowance and the related earnings threshold would also go some way to supporting those carers who are unable to work full-time. This can not only result in better care for the patient but also decrease some of the financial stress felt by the caregiver.

Depression in the patient and caregiver, and also caregiver burden, can also be affected by the language difficulties experienced by the patient. This is because language difficulties lead to the social exclusion of AD patients and intensify a significant decline in QoL (Klimova, Maresova, Valis, Hort & Kuca, 2015). They also have an immense impact on family members and caregivers who need to communicate with their loved ones to meet their needs. Language impairments include difficulties with word comprehension, finding the relevant words, the meaning of words and naming (Ferris & Farlow, 2013). This, therefore, means that AD patients are not able to effectively express themselves and as a result are less able to communicate with their family members, relatives and friends, resulting in social exclusion.

Since the effects of social exclusion can be severe, it is important to decrease them and preserve the practical social rights of individuals with AD. One way to improve their language skills is to prescribe donepezil (Evans et al., 2000). As discussed, this drug can help to reduce symptoms of AD, including decreasing language difficulties which can go a long way in reducing the exclusion felt by AD patients, since they can regain some control over their interactions with others. Although this medication can be effective, reasons such as side effects and ineffectiveness can mean that it will not work for all AD patients. Therefore, given the prevailing image of the social incompetence of patients with AD, one approach might be to work on the cultural representation of AD, and neurological disorders in general. Equipping wider society with tools and awareness could mean that AD patients are received with greater competency and understanding, as opposed to social exclusion and lack of understanding.

The stigma associated with AD and dementia remains a barrier to the increased inclusion of AD patients (Bond, Corner & Graham, 2004). Therefore, the effects of stigma need to be neutralised to increase the social participation of this marginalised group. One way to do this is to increase interactions between the patients and the wider public. Not only will this have the long-term effect of reducing stigma, as individuals become more educated about the illness, but can also increase social inclusion of AD patients by increasing their interactions with other people. An example of this is the Alzheimer’s Society Initiative – Dementia Friends. This programme involves educating volunteers about dementia so that they can spend time with affected individuals and is highly successful (Mitchell et al., 2017). Dementia Friends, therefore, raises awareness and hence helps to reduce the stigma, whilst also immersing dementia patients back into the community.

AD also has wider social implications when considering the economic bearing. Understanding the socioeconomic impact of AD is of key importance for determining the value of programs for diagnosing, treating, and preventing AD, as well as research and development investment decisions on new technologies. According to Wittenberg et al. (2019), the total annual cost of care for dementia in England alone is approximately £24.2 billion. Therefore, in addition to the human suffering caused by the disease, Alzheimer’s is also creating an enormous strain on the NHS and health sector. On top of the direct, there are further hidden costs when considering factors such as the deterioration in mental health experienced by many AD patients and their carers and side effects associated with the medication used to treat these illnesses (El-Hayek et al., 2019). It is therefore critical that this economic impact is acknowledged and analysed with the brevity required. Without this, policymakers cannot make informed decisions or understand whether policies, designed to meet this challenge, are economically effective. Moreover, further investments in research need to be made in an attempt to find better treatments and improve the way diseases like Alzheimer’s are diagnosed. With research investigating better treatments, potential prevention methods and social care strategies, the impacts of AD discussed thus far are likely to be reduced.

One area of research that could significantly reduce the economic burden of AD is multimodal, non-pharmacological interventions for dementia resulting from AD. Although this type of intervention is less utilised among medical practitioners, the latest NICE guidance calls for them as the first point of call (Chalfont, Simpson, Shukla, Venkateswaran & Milligan, 2018). Recent review findings have identified a diverse combination of interventions, including cognitive enhancement therapies, physical exercise, psychological and psychosocial therapies, nutrition and diet, sleep hygiene, stress reduction, detoxification and hormonal health (Chalfont, Milligan & Simpson, 2018). In 90% of the studies reviewed, participants were reported to have cognitive improvements, stability with their dementia or a delay in their decline. This provides a more integrated approach to reducing AD symptoms, and in doing so, further problems such as depression, side effects of drugs, and caregiver burden could also be reduced as a result. This would, therefore, be a more cost-effective treatment, not only because it reduces reliance on the NHS and drugs, but in reducing these further psychosocial issues associated with AD hidden costs are also reduced.

In essence, AD can be a debilitating illness for those directly and indirectly affected by it. The cognitive impairments it leads to can produce a series of psychosocial impacts that can have serious and far-reaching consequences. Some of these include a deterioration of mental health, negative effects on caregivers, economic and financial burdens and social exclusion, as discussed here. Whilst there are strategies in place to moderate these impacts, such as drugs, therapy, funding and volunteering, further research needs to be conducted in these areas to find the best methods of helping AD patients so that they can feel as healthy and included as possible.   

16 December 2021
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