Well-being in dementia and mild cognitive impairment.

Abstract

In several ways, dementia is the final frontier for the march of Positive Psychiatry. In the recent months, International Psychogeriatrics has devoted two issues to the theme of Positive Psychiatry, reflective of the rise of this movement in the consciousness of the medical community as well as the public (see editorials: Haupt, 2019; Jeste, 2018). Yet, many people continue to see concepts such as flourishing, successful aging, meaning in life, wisdom, and wellbeing as not being applicable to (if not outright incompatible with) the lived experience of individuals with dementia. It is precisely for this reason that it is refreshing to see four articles in the current issue of International Psychogeriatrics extend the domain of Positive Psychiatry and apply these notions of well-being to among those who are most in need of it—the individuals with cognitive disorders. A study from Belgium by Dewitte and colleagues (Dewitte et al., 2019) is a cross-sectional study of 138 older adults living in residential care with a diagnosis of Alzheimer’s disease. The investigators used questionnaires administered in a structured interview format to measure meaning in life (using a subscale of Meaning in Life Questionnaire-Short Form), life satisfaction (modified version of Satisfaction with Life Scale), depressive symptoms (Geriatric Depression Scale), and general cognitive status (Mini-Mental State Examination or MMSE). The researchers found that meaning in life was positively correlated with life satisfaction and negatively with depressive symptoms. In addition, they noted a moderating influence of cognitive status, such that the relationship between meaning in life, life satisfaction, and depression was stronger in subjects with lower cognitive functioning. Themoderating influence of cognitive status is an important variable because it seemed that, contrary to popular perception, meaning in life became more – and not less – important as cognitive functioning worsened. This is particularly important since the researchers also noted that depressive symptoms were more severe in subjects with more severe cognitive impairment. The study demonstrates that the perception of meaningful life is a critical psychological need for successful well-being in individuals with dementia. Miller and colleagues (Miller et al., 2019) studied 42 dyads comprised of a hospitalized patient with dementia and a family caregiver (a majority of these caregivers were adult daughters). Well-being was assessed for both individuals with dementia and caregivers with Quality of Life-Alzheimer’s Disease Scale (QOL-AD) and Center for Epidemiologic Studies-Depression Scale (CES-D). Strain in the relationship was measured along three dimensions: cognitive impairment (measured in individuals with dementia using MMSE), care-related strain (measured in caregivers) and relationship strain (measured in individuals with dementia as well as caregivers). Relationship strain was associated with lower quality of life in the opposite member of the dyad. Worse cognition in the individual with dementia was associated with worse quality of life for the caregiver. The perception of relationship strain by the individual with dementia was related to depressive symptoms in the individual, and increased level of care-related strain was associated with caregiver’s depressive symptoms. These findings highlight the fact that the quality of the dyadic relationship is inseparable from the well-being of individuals with dementia. Capturing a broader picture of well-being requires an assessment of well-being of both the individuals with dementia and their family caregivers, and the various strains in their relationships. A systematic review andmeta-ethnographic analysis from the UK (Bosco et al., 2019) explored the experience of agency in individuals with dementia. Based on a review of 20 selected studies, authors identified three third-order constructs relating to decision-making pathways and degree of autonomy: autonomous decision-making, shared decisionmaking, pseudo-autonomous decision-making. They also found that which mode of decision-making takes places depends on the severity of cognitive impairment, the urgency of the situation, the ability of the person to engage in metacognitive processes such as self-awareness, and the behavior of the caregiver. The authors discuss strategies to promote autonomous decision-making. These strategies target metacognitive regulation to understand and respond to the situation, and can include daily diaries, reminders, use of technology, simplifying the number of available choices to the most important ones, and use of advanced directives. The review and meta-ethnography did not delve into International Psychogeriatrics (2019), 31:5, 603–606 © International Psychogeriatric Association 2019