Are We Ready for Mental Health Aging?

Our society is aging. For the first time in Canada, there are more people aged 65 years or older than people aged less than 15 years. Our aging as a society is due to our successes in preventing, treating, and managing several health-related conditions that led to early mortality a few decades ago. However, as our bodies are maintained in a relatively good health into our later decades, our brains continue to undergo the aging process and the wear and tear of experiences, rendering us susceptible not only to cognitive and functional decline but also to brain diseases that emerge late in life and that are associated with or triggered by brain aging. In this issue, 2 lines of endeavors that could help our society prepare itself for the sequelae of growing older are reviewed and discussed.

In the first review by Dumas, ¹ the author reviews what is meant by cognitive aging and then focuses in depth on a promising approach to combat cognitive aging and possibly prevent cognitive decline and dementia among women using hormone therapy. The literature in this area of investigation has been complex and controversial. At this point in time, there is no definitive evidence that hormone therapy and clinical trials are needed to confirm their efficacy. However, the author nicely summarizes the subtleties among the various types of studies that led to contradictory results and presents elegantly a model that could explain this mixed literature, focuses on the critical period concept, and could guide future study designs. The author ends by reviewing other promising lifestyle interventions that could prevent or slow cognitive aging, including diet, exercise, and mindfulness-based interventions. Dumas’s review focuses on interventions that could have an impact on cognitive aging (i.e., in a brain health state that is not affected by a particular mental health disorder). However, these same interventions could theoretically be beneficial to older individuals, even if they are suffering from a mental disorder. Among the most common mental disorders in late life are neurocognitive disorders (e.g., Alzheimer’s dementia, anxiety disorders, and depressive disorders). Thus, future studies could not only further investigate the impact on cognitive aging of the interventions described by Dumas and potentially their combinations across different time windows in late life but also investigate them within the context of mental health disorders. The main rationale is that a brain that has been inflicted with a mental disorder could respond differently to these interventions and could have different critical periods.

Notwithstanding the need for further research on the strategies described by Dumas as well as other strategies to combat cognitive decline among healthy or mentally ill older adults, to have a societal impact, we need to develop novel and scalable approaches to deliver these interventions. Dham et al. ² focus on this particular problem by presenting a systematic and comprehensive review on collaborative care for psychiatric disorders in older adults. Dham et al. nicely summarize the elements of a robust collaborative care model. The authors then identify the strengths and challenges of collaborative care for the treatment and management of depression in late life, as evidenced by several large and well-designed trials. The authors also identify a critical gap in the literature on collaborative care for all other mental disorders in late life, including alcohol use disorders, anxiety, bipolar disorders, and dementias. Given that most older adults with these brain disorders will be treated by their primary care providers rather than by specialists, it will be critical for our preparedness to cope with the tide of older adults with brain disorders to develop the right collaborative care model for these other disorders as well as for individuals suffering from comorbid disorders (e.g., developing Alzheimer’s dementia on a background of a lifelong bipolar or psychotic disorder).

More is to be done to prepare ourselves for an aging society in which members will experience cognitive aging and many will also experience a brain disorder. These reviews present where we stand with respect to hormonal and lifestyle strategies as well as models of collaborative care delivery. Other treatment and delivery tools are also being developed to combat cognitive decline in growing society. For example, transcranial direct stimulation, an electrical form of brain stimulation that is portable and scalable, is being investigated to prevent dementia (e.g., NCT02386670). Telemedicine is a growing form of delivering care that could reach a large sector of older adults with mobility challenges. Such novel forms of scalable interventions and accessible models of care will also need to be studied within the context of the strategies and collaborative care models described by Dumas and Dham et al. for a potential larger impact on our society.