The objective of this analytical cross-sectional study was to find the association of mentally traumatic events in early life with cognitive decline in elders. Respondents who are above the age of 50 years, residing in old age home and patients attending OPD, who were mentally stable. 130 respondents were selected with the Purposive Sampling method. Pre structured questionnaire which was prepared to understand the demographic data, stressful life event screening questionnairewas administered to identify and understand the level of the stressful events in their lives. The cognitive status was assessed by collecting data using mini mental health scale. The data revealed that, 38.5% of them showed mild cognitive impairment and 16.9% respondents showed severe cognitive impairment. When measuring the range of cognitive impairment, 55.4% of the respondents showed increased odds of dementia, which suggest that chances of these respondents having cognitive decline is high.
SPSS- statistical package for the social sciences, SLESQ -the stressful life events screening questionnaire, DM -diabetes mellitus, HTN -hypertension, PTSD -post traumatic stress disorder.
Dementia is defined as the progressive disorder characterised by gradual loss of memory and cognitive decline. The “diagnostic and statistical manual of mental disorders” defines ‘dementia’ to be a loss of either one of the cognitive functions which can either be that of movement or actions, language or verbal functions and that of skills or execution. This change in an individual should be considerable comparing to their life in the past. (1)
The incidence of dementia or cognitive decline is on a rise among the elderly, found out to be 11.67 per 1000 person-years for those more than 55 years of age and significantly higher in advancing age. (2)
Diagnosis of dementia in an early stage becomes very essential considering the lack of scope for cure after a significant progress of the disease. Hence, finding out the various factors responsible in onset of dementia is of prime importance. Head injury (3), life style disorders like smoking, excessive alcohol consumption, iatrogenic causes, stroke, genetic mutations, levy body formation and psychological factors like cognitive impairment (4) , late life anxiety, geriatric depression, post-traumatic stress disorder(4) are some of the risk factors that cause the onset of dementia symptoms in an individual above the age of 50(5).
In context to early detection of dementia before the symptoms appear, identifying factors in younger age (6) that can cause cognitive impairment becomes necessary to prevent the remote changes in future years in an individual. Therefore, it becomes important to correlate factors like mental trauma, depression and stressful life in younger age (6) to the cause cognitive impairment in elderly, allowing increased scope in managing the mental disturbances by various methods, thus preventing cognitive decline and dementia.
2. AIMS AND OBJECTIVES
To find the association of stressful and mentally traumatic events in early life with cognitive decline in adults and to understand the importance of identifying and addressing the psychological changes in an individual. Also, to suggest various methods to prevent the cognitive decline after a psychological trauma.
3. MATERIALS AND METHODS
3.1 STUDY POPULATION
An analytical cross-sectional study was done for 6 months from December 2018 to May 2019. The study was conducted on the respondents who are above the age of 50 years, residing in St. Joseph Prashanth Nivas, Mangalore, India and patients attending the out-patient unit of Father Muller Homeopathic Medical College and Hospital, Mangalore, India, who were psychologically healthy and gave consent for study.
Respondents above the age of 50 years, who gave the consent for the study, and went through an experience of a well-marked stressful event in early life were considered for the study. The individuals who were measured using the “STRESSFUL LIFE EVENT SCREENING QUESTIONNAIRE” and then showed a positive response of a stressful life event only were considered for the study.
Elders with poor health condition and serious impairment of health, and those individuals who were clinically diagnosed with any psychiatric condition were excluded from this study.
With 95% confidence level and 95% power with reference to (4), the sample size came up to be 130 using the formula N=Zα2 Ϭ2 /d2, where, Zα = 1.96 at 95% confidence level Ϭ= standard deviation= 2.9, d = 5% of mean. (4) Respondents were selected as per the sample size calculation with the non-probability (purposive sampling)
A pre-structured questionnaire was prepared to understand the demographic data with information such as age, gender, academicals and occupational status, personal and familial past and present medical history, patterns of sleep, appetite, thirst and daily routine.
The stressful life event screening questionnaire (9) to identify and understand the level of the stressful events in their lives was administered. The stressful life event screening questionnaire consisted of questions that identified and graded the stressful and traumatic events in life such as physical or mental assault, sudden unexpected death of a close acquaintance by unnatural causes, childhood trauma and high graded stress relating to family, society and work space. The identification was done on the basis of Yes/No questions and the intensity of the event calculated by the repetition of the event, the impact it had on the daily activities and the clarity of the past event on the present day. The scale was applied, until 130 elders as per sample size calculation having stressful life events were found
On the selected 130 elders with a graded stressful life event, the present cognitive status of were assessed by collecting data using mini mental health scale questionnaire, (6) which is 10 questioned scale which calculates the present cognitive state of the individual based on memory, intellectual and abstract techniques which is measured with respect to the maximum of 30 points.
3.3 STATISTICAL ANALYSIS
Analysis was done by using descriptive statistics, association of different scales with demographic data was done using chi square test. Statistical package SPSS vers.23.0 was used to do the analysis. p <0.05 was considered as significant.
The present study shows the various stressful events of the respondents and their cognitive status. The demographic data of the respondents was also collected. The adults of the study population having stressful events in their life were selected for the study and 130 respondents were chosen. Among whom, 61.5% were males and 38.5% were females. 26.2% were in the age group of 60-65 years, 20% in the age group of 55-60 years, 18.5% in the age group of 50-55 years and 13.8% in the age group of 65-70 years and 9.2% are above 75 years.
Among the respondents 46.2% had unskilled type of occupation, 20% of them were managing the house work and 6.2% of them were professionals. 4.6% of them had post-graduation of education, 23.1% completed high school level, and 13.8% are illiterate. It was seen that 56.5% of the respondents were married, 35.4% were unmarried and 1.5% of the respondents were divorced.
It can be understood that 81.5% of the respondents lived in nuclear families and only 18.5% of them were living in a joint family setup. Although 60% of the respondents had no significant family history, it was seen 26.25% of the respondents had family history of diabetes mellitus, 10.6% of them had family history of hypertension and 1.5% of them had family history of dementia.
35.4% of the respondents reported with disturbed sleeping patterns and it was reported that 23.1% of the respondents were addicted to alcohol, 7.7% to smoking and 7.7% to tobacco chewing.
Table 1: Distribution of stressful life events among the respondents:
|Life threatening illness||4||3.1||126||96.9|
|Life threatening accident||24||18.5||106||81.5|
|Physical force/weapon used in robbery or mugging||4||3.1||126||96.9|
|Any death due to accident, homicide, suicide||36||27.7||94||72.3|
|Sexual harassment against will||2||1.5||128||98.5|
|Touched parts of your body against will||2||1.5||128||98.5|
|Physically abused as a child||22||16.9||108||83.1|
|Physically abused as adult||8||6.2||122||93.8|
|Witness of any death, injury or assault||5||3.8||125||96.2|
|Helpless with fear||2||1.5||128||98.5|
The stress life events of the respondents were assessed by the standard scale, ‘the stressful life events screening questionnaire (SLESQ)’, a 13-item self-report measure for non-treatment seeking samples that assesses lifetime exposure to traumatic events. This scale is used to measure eleven specific and two general categories of events, such as a life-threatening accident, physical and sexual abuse, witness to another person being killed or assaulted, are examined. For each event, respondents are asked to indicate whether the event occurred (“yes” or “no”), their age at time of the event, as well as other specific items related to the event, such as the frequency, duration, whether anyone died, or was hospitalisation, etc.
The present research clearly depicts that most of the respondents (40%) had stressful event like miscarriage, 27.7% of them had experienced the stress due to death of the family member due to accident or suicide, 21.5% of them had faced mental harassment in the family, and 18.5% of them had experience life threatening accidents. There were other responses like illness, physical harassment, sexual harassment, helplessness, etc. with minimal percentage of respondents.
This result shows the various stressful events faced by the respondents in the present study.
4.1 COGNITIVE IMPAIRMENT
Cognitive function may decrease with the effect of few risk factors like clinical conditions like hypertension, decreased quality of life and stressful events in the life of any individual. Dementia which is cerebrovascular disease is the leading cause in dementing illness. Hence in order to find the association of dementia and stressful events this screening was conducted. This scale measured the tests of orientation, attention, memory, language and visual-spatial skills.
Table 2: Cognitive impairment
|Severe cognitive impairment||22||16.9|
|Mild cognitive impairment||50||38.5|
|No cognitive impairment||58||44.6|
As the objective of the study the researcher measured the cognitive status of the respondents by using mini mental state examination. The data reveals that 44.6% of the respondents do not have any cognitive impairment. However, 38.5% of them show mild cognitive impairment, and unfortunately 16.9% of the respondents show severe cognitive impairment. The cut-off point of cognitive impairment is <24.
This scale also measures the range of cognitive impairment, the data of the present study depicts that 55.4% of the respondents shows increased odds of dementia, which suggest that chances of these respondents having cognitive decline is high.
Fig 1:COGNITIVE IMPAIRMENT
Table 3: Association between MMSE vs. marital status
|x2=24.478; p=0.002 hs|
It was found that marital status has significant association with cognitive impairment. Among the unmarried, maximum of them were in the group of moderate or severe cognitive impairment compared to married respondents (p=0.002)
Table 4: Family medical history vs. cognitive impairment
|Family medical history||Total|
|x2=23.285 p=0.003 hs|
The percentage of cognitive impairment in family history of diabetes mellitus and hypertension was found to be significant compared to other disease. (p=0.003). Surprisingly, the family history of dementia on those having cognitive impairment was nil.
Table5: Life threatening accident vs. cognitive impairment
|Life threatening accident||Total|
Out of the 24 life threatening accidents which occurred among the subjects, 16.7% are having severe and 41.7% have mild cognitive impairment. (p=0.0934)\
Table 6: Physically abused as a child vs. cognitive impairment
|Physically abused as a child||Total|
X2=7.18 p=0.028 sig
Physical abuse in childhood has a good association with cognitive impairment (36.4%). The association was found to be statistically significant (p=.028)
Stressful life events have an impact on the cognitive decline of the individual. This clearly shows in the present study that 55.4% of them have cognitive impairment. Association between marital status, family medical history and sleep pattern with cognitive impairment was found to be significant. Similarly, association of stress of physical abuse in childhood with cognitive impairment was found to be significant. The research found the similar result in the review of literature, study conducted by Guerry M Peavy et.al(10). Similar result was seen in the study conducted by Lena Johansson et.al(11). However, further research is suggested which could continue with the follow up of these respondents in order to see the progression of cognitive impairment leading to dementia.
- Since dementia is only identified after a certain amount of progression of the pathology in the brain, it is only a good practice to identify various risk factors, which on preventing early in life by various measures, can considerably prevent the progression of the disease altogether.
- Every OPD, Clinics or any health setup that deals which psychological trauma or Post traumatic rehabilitation, may consider the formation of cognitive impairment as a risk factor in an individual and applying techniques such as counselling, psychotherapy and supportive therapies, may help in managing the future-effects of the untreated mental trauma
- A protocol in every health setup may be administered in order to identify any risk factor in patients of every age with respect to the possibility of avoiding the initiation of the disease.
- Homoeopathically, identifying the cause (12) even before the effect is shown out, may help as a preventive measure to avoid the psychological ailment that can occur in the same way that any morbid disease is prevented by removal of the causative factor (13) . Administration of a constitutional remedy, considering the patients as a whole, having included the factor of a history of psychological trauma, may help in removal of that particular factor, which may hinder the treatment of other morbid phenomenon. (14)
- Homoeopathic intervention for the PTSD symptoms that can occur as an acute manifestation of the mental disease, may be treated using the short acting remedies that is selected based on the symptoms of PTSD shown by the individuals ,which will neurologically decrease the after effects of the trauma (15)
- Further researchis proposed in therapeutically treating the PTSD symptoms and the psychological stress through homoeopathic remedies.
5.2 FINANCIAL SUPPORT AND SPONSORSHIP
This study was financially supported by Father Muller Homeopathic Medical college and Hospital, Mangalore, India
5.3 CONFLICTS OF INTEREST
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Shreyank Kotian *
Father Muller Homeopathic Medical College and Hospital
Mangalore, Karnataka, India
Dr Girish Navada U.K, BHMS, MD (Hom),
HOD, Dept. of Psychiatry
Father Muller Homeopathic Medical College and Hospital
Mangalore, Karnataka, India