Podcast – Happiness as Medicine: Well-being in Dementia Care

Voice Over:

The Dementia Researcher podcast, talking careers, research, conference highlights, and so much more.

Dr Sam Moxon:

Welcome to the Dementia Researcher podcast. I'm Dr. Sam Moxon, and today, I'm joined by three of the people behind the World Happiness Report to deliver what I hope will be an exciting and insightful episode, which have entitled Happiness as Medicine: Exploring Well-being in Dementia Care.

So, guys, let me start by setting this theme. The World Happiness Report is an annual publication that ranks global happiness levels based on individuals' assessments of their lives. The report provides viable insights into the factors that contribute to happiness and well-being across different countries and age groups. We're very honoured to have with us some of the authors of this year's report. And today we're going to specifically take a look at chapter four, which really interestingly addresses the associations between well-being and dementia.

So, joining us today are Emily Willroth, an assistant professor at Washington University in St. Louis, Karysa Britton, a clinical psychology PhD student, also at Washington University in St. Louis, and Kyrsten Hill, a postdoctoral researcher, again from the same institute. Their collaborative work has shed light on how higher levels of well-being can potentially act as protective factors against dementia and improve the quality of life for those living with the condition.

So, what I want to find out is if Ingrid Bergman was right when she famously said happiness is good health and a bad memory. So, we're going to discuss the findings, the implications for dementia care, and practical strategies to improve well-being among older people. So, let's welcome Emily, Karysa, and Kyrsten to the podcast. So welcome, guys. Thank you for joining us. And why don't you all introduce yourselves properly and tell us something that made you happy this week. So, Emily first, and then we'll take that same answer from Karysa and then Kyrsten. So, Emily, what made you happy this week?

Dr Emily Willroth:

Thank you so much for having us. My name is Emily Willroth. I direct the WELLab here at Washington University in St. Louis. And this week what made me happy was spending time with family. My mom came in from out of town and spent the weekend with me and we went to see Shakespeare in the park.

Dr Sam Moxon:

Oh, how was that? Was it a particular play or...

Dr Emily Willroth:

Yeah, they put on as you like it, and it was really good.

Dr Sam Moxon:

That sounds really nice. Where we are, we're not too far from Stratford-upon-Avon where Shakespeare was born, and we keep talking about going and seeing a play there. I haven't been yet, but it's still on the list, so that's a nice way to start the show. So, Karysa, what about you? What's made you happy this week?

Karysa Britton:

Thanks again for having me. I'm so excited to be on the podcast. So, what made me happy this week was I found a new Instagram account with a little dog who got adopted. He's 10 years old and he just looks like a puppy and he's the happiest little guy. So yeah.

Dr Sam Moxon:

Yeah, dogs make everything happier.

Karysa Britton:

Yes, they do.

Dr Sam Moxon:

A person doesn't like dogs, you can't trust them, we always say. And Kyrsten, what about you?

Dr Kyrsten Hill:

Thanks for having me as well. One thing that made me happy this week is my husband and I have been renovating our house. It's a fixer-upper we bought a couple of years ago, and we just kind of put on the final touches for the hall bathroom. So, it's very exciting to see it coming together.

Dr Sam Moxon:

A sense of achievement when you get those kinds of projects done, isn't it so?

Dr Kyrsten Hill:

Yes, definitely.

Dr Sam Moxon:

That's really nice. Well, we hope you guys enjoy the episode, and we're going to get into it now. Let's dive into the topic then. So, I'm going to come over to you first, Emily. And I'd like to ask if you can start by telling us a bit about your background and the work you do at WELLab and what individually drew you to studying the relationship between well-being and cognitive health.

Dr Emily Willroth:

My background and my PhD training is in psychology, and so I really focused on understanding what well-being is and how it changes across the adult lifespan. So, in the WELLab, we consider well-being to be lots of different aspects of how we think and feel that are related to feeling a sense that our life is fulfilling and satisfying. And so, as I was going into my post-doctoral training, I really wanted to understand links between psychological well-being and physical and cognitive aspects of health. So, I sought out training in this really unique interdisciplinary department called Medical Social Sciences at Northwestern University in Chicago, and there I had the opportunity to collaborate with researchers at RUSH Alzheimer's Disease Centre. And with my colleagues at RUSH, I learned a lot more that I didn't know during my PhD training about dementia, and I found it to be really fascinating, given that there are really limited availability of biomedical treatments, and yet this large and growing literature on psychosocial and lifestyle factors that can be useful for dementia prevention.

And so, I saw a real opportunity to bring in my background in well-being science and psychology and make a potential difference in this really important area of research. And so, when I started my position at Washington University in St. Louis, I started the WELLab it stands for well-being and emotion across the lifespan and in the WELLab, we're really interested in how these different components of what it means to be psychologically well can impact risk for age-related diseases such as dementia, as well as how different health events and aspects of the ageing process might impact people's well-being.

Dr Sam Moxon:

That's fascinating, because obviously on dementia research we have different bloggers who write about different topics every week, and they all come from very different backgrounds. So quite widespread. And I think what this episode is hopefully going to highlight is that there's so many different avenues of exploration when it comes to dementia. So often we think so strongly about it being just very cell biology-based, and we don't think about all these different environmental factors that have a deep-rooted impact on our biology. So to bring me on to my next question, Emily, your research, highlighted in the World Happiness Report, it shows that higher well-being is linked to a lower risk of developing dementia, which I find fascinating, and I wonder if you could explain some of the key findings and what their implications could be in how we look at how we can prevent dementia and maybe even further than that as well.

Dr Emily Willroth:

Research both from our group but also for others has found that people with higher levels of well-being, whether that is feeling more purposeful or more satisfied with their lives, experiencing more positive emotions, are less likely to develop dementia across the lifespan. And when they do develop dementia, they are typically diagnosed later. In addition, people with higher levels of well-being typically experience less age-related cognitive decline.

And so that provided some evidence that there might be protective effects of well-being, but there could also be other explanations for that as well. So as a next step in our lab, we were really interested in looking at the temporal dynamics of changes in well-being across older adulthood, as well as changes in cognitive function. And most recently, what we found is that with in-person increases in well-being over time are associated with less steep subsequent cognitive decline, even when accounting for individual differences in people's levels of well-being and in their levels of cognitive function. And what that does is it brings us one step closer to potentially being able to make causal inferences. And the reason that that's important is it means that if well-being is indeed protective, we may be able to intervene either with individuals or with policy at the population level to enhance well-being and lower risk for subsequent dementia.

Dr Sam Moxon:

I like the way you used causal, because so often, people will say, "Well, correlation is not causation," but if you can find a causal link, that's really hard to dispute and you'll have massive implications. So, Karysa, I'm going to come over to you now, if you don't mind. I'm going to ask you what measures of well-being did you find to be the most strongly associated with the reduced risk of developing dementia?

Karysa Britton:

So generally, we find that sense of purpose is consistently associated with not only reduced risk of dementia but also reduced risk of mild cognitive impairment, so the stage before dementia, and mortality. And interestingly, sense of purpose has also been linked to a greater resilience to dementia-related neuropathology. And so, what that means is that we find older adults with higher levels of sense of purpose tend to experience better than expected cognitive functioning even when dementia-related disease processes are present in the brain. And so, on the other hand though, life satisfaction, which is another component of well-being, has more mixed evidence. So, some researchers have found evidence to suggest that higher life satisfaction is associated with a reduced risk of dementia and of mortality, while other research has suggested no such association. So, there's kind of a mixed picture there, and we're currently working on some research to disentangle why we see these discrepancies between the two different components of well-being and their risk, or their associated risk for developing dementia.

Dr Sam Moxon:

If you don't mind, I'd like to ask another question based around that. So, when you say sense of purpose was strongly associated with reducing risk, did you have any indication of the kind of things that give someone a sense of purpose and something that people could do to give themselves a sense of purpose? Because it seems like it's all around feeling like you've got something to be responsible for and that becomes mentally engaging. Is it that kind of relationship?

Karysa Britton:

So, when we think of sense of purpose, we're thinking about the feeling that you have a direction or a sense of meaning in your life. So that can really vary from person to person. I know something that gives me a sense of purpose is well-being research, for example, whereas for someone else, that might be their family or another type of job that they're involved in.

Dr Sam Moxon:

I wonder if also there's almost a chain reaction where if you feel you've got more sense of purpose and feel more fulfilled, you're then more likely to make more positive changes as well, which may also then further reduce the risk. We've learned a lot about diet and exercise on this show, and I wonder if someone feels they've got more sense of purpose, they're more inclined to exercise more, or eat better. I wonder if that could play a role as well. What do you think about that?

Karysa Britton:

That's exactly right. I think you're on the right track with that line of thinking. You tend to see that exact kind of pattern. You have an increased sense of purpose, you're more likely to exercise more, you're more motivated to eat healthier and to do things that are going to bolster your health in general.

Dr Sam Moxon:

It's really interesting. Kyrsten, I'm going to come to you now. I'd like to ask you what's some of the potential mechanisms that might explain why high well-being protects against dementia? We've just touched on sense of purpose, but any other things that might explain why we're seeing this association?

Dr Kyrsten Hill:

This is a really important question that researchers are still working on addressing, and it actually taps into some of what we were just talking about. What we know right now is that well-being may protect against dementia through a number of different pathways, social, behavioural, and biological pathways. And one of the big ones is actually healthy lifestyle behaviours. And so, we know that well-being promotes social engagement, but also engagement in health behaviours like physical activity, healthy eating, abstinence from smoking. And so, this could be one of the mechanisms linking well-being to lower dementia risk.

Yeah, it's also possible that well-being may directly influence biological processes like immune and cardiovascular functioning. And then a third possibility that people have looked at has to do with stress. And so, stress and particularly chronic stress has negative effects on physical and cognitive health. The stress hormone cortisol has been linked to problems with memory. And so, if well-being is acting as a protective factor against stress, this buffering effect of well-being may also be part of what's playing a role in that link between well-being and lower dementia risk.

Dr Sam Moxon:

It's so easy to think of well-being and happiness as just a very almost spiritual or philosophical thing, but there is a lot of biochemistry behind it, isn't there? It's biochemical reactions that release certain molecules, certain hormones that act on the brain, and it can be so easily affected by so many different factors. It's one of those things that you might not necessarily think of, but as soon as someone says a well-being has an effect on how well the brain ages. Suddenly, you think, "Oh, actually that makes a lot of sense," because anytime you're stressed and those stress hormones are circulating and the immune system is activated, that's going to obviously damage the brain. So, it's really interesting. So, is there a particular stage in life when you think well-being has the most impact on future cognitive health?

Dr Kyrsten Hill:

That's another really good question, and it's still an open question right now. So, the short answer there is that we don't quite know yet, but on the one hand, the benefits of well-being on cognitive function may kind of build and accrue over time. And so, in that way, it would be important to promote well-being in early and middle adulthood to essentially set the stage for this positive health trajectory that could lead to better cognitive functioning in the long term.

On the other hand, it's also possible that well-being is the most protective in older adulthood when the risk for dementia is greatest. And so, there's been some research that has started to look at age as a moderator, and that found that the relationship between sense of purpose specifically and cognitive decline was strongest among older adults, suggesting that maybe there are certain windows where well-being is playing a different role. But in this research and most research looking at well-being and cognition, the samples used we're really focused on late midlife and older adulthood. And so, to really answer this question, we need more research that looks at individuals across the lifespan from young adulthood through older adulthood so we can get a better picture of when well-being is most important and playing the biggest role.

Dr Sam Moxon:

I think that's a really good point as well because obviously we know it's a symptom of diseases that manifest over decades, and it's a very slow process. And so, it's almost you wonder whether it is a thing that has to be perpetuated throughout or whether there are particular moments where that's more powerful. So, I'd be interested to see how that develops as the research spreads.

Emily, your chapter also considered ways that we can centre well-being in dementia care settings to help people live well with dementia. And so, I find this really interesting because we so often think that particularly in the UK, I'm not sure what it's like in America, that when someone has dementia, there's not a lot that you can do for them. But this is now starting to look like maybe we can. So, what are some of the ways that the environment can support the well-being of people who are actually living with dementia?

Dr Emily Willroth:

This is a great question, because it really highlights the fact that it is possible to live well with dementia, and that there are things that we can do in the environment to help support the well-being of people living with dementia. So, for example, research suggests that people living with dementia as well as older adults more generally prefer to age in place, or in other words, continue living in home or a home-like environment for as long as possible. So, providing resources and supports that enable individuals living with dementia to remain at home and to do so safely for as long as possible is one way that we can support the well-being of people living with dementia.

Increasingly, there have been different care models around the world that help individuals living with dementia, receive memory care in environments that are familiar and comfortable. So for example, in dementia villages, where groups of individuals living with dementia are able to access grocery stores and parks and familiar environments within a safe memory care setting, and even in traditional memory care settings such as nursing homes, assisted living facilities, there's different things that we can do in the environment to support the independence of people living with dementia as well as that sense of living in a comfortable and familiar environment and all of those things can support the well-being of people living with dementia.

Dr Sam Moxon:

That's a really important point, because my grandfather had Alzheimer's disease, so we think it was Alzheimer's disease, we never actually got the full diagnosis of what was causing his dementia. And the story I tell people is a story that so many people have been told by other people in the past that as soon as he had to move out of his home and into care, it accelerated, and then when you had to go to hospital, it accelerated once again. So clearly, there's a big role to play for those kind of environmental factors. So, Kyrsten, are there particular activities or strategies that has been shown to support well-being in people living with dementia? Obviously, these are the people who need that as much as possible.

Dr Kyrsten Hill:

Yeah, definitely. So, zooming into that more individual personal level, two of the broad factors that we see are social engagement and engagement in pleasant and personally meaningful activities, and this can really help to promote well-being in people living with dementia. And this can include a range of activities, so things like exercise programmes, cultural arts interventions, which could be things like art therapy, music therapy, dance therapy, even things like animal-facilitated therapy, or one that's becoming increasingly popular in people living with dementia is using reminiscence interventions that basically promote the person living with dementia to reminisce and share memories and stories from their past either in a one-on-one or a group setting.

And so, kind of across the board for all of these, one thing that we see is that research suggests that these activities are most effective when they're tailored to the individual. And so, I think this is an important thing to keep in mind that instead of just taking a one-size-fits-all approach, it can be better to take a more person-centred approach where we think about, for this person, what are their interests, what are their hobbies and their passions, and try to use that as a starting point.

Dr Sam Moxon:

That's a really, nice philosophy. Just to go back to personal experiences. My grandfather started painting again, and that seemed to make a big difference for him for a while. And in the UK, we have a charity called Dementia Choir, which gets dementia patients to come together and sing and the [inaudible 00:19:42] that has massive positive impacts on them as well. So, it's a really nice, because it's so easy to think that these people who have dementia, it's such a debilitating illness that you think quality of life goes out the window, but there's still so much that can be done to give people quality of life as they're going through that battle. So, Emily, on that note and how we get this into practise and start to help people, a question I've got for you is how can public health policies and community programmes like one that I've just talked about, how can they incorporate your findings to better support cognitive health in the ageing population?

Dr Emily Willroth:

I think one major take-home message for public policy makers from this research is the importance of really prioritising well-being and mental health more broadly as a public policy and a public health issue. So, for example, we know from decades of research that access to economic opportunities as well as economic equality support the well-being of entire populations, and those types of population level, policy level, things that we can do to promote well-being in the population may also then have the added benefit of lowering risk for dementia.

In addition to those sort of broad things, there is some research suggesting that specific policy changes and interventions, things like creating green spaces in urban areas, having centres and public spaces that foster community building across the lifespan and in older adults in particular, can improve well-being. But a lot of those more specific policies are likely situated within their local context. So, I think the best thing that policymakers can do is to start actually measuring population level well-being and tracking that as an important outcome and goal of policy changes.

In addition to this, that's sort of on the prevention side. So, what can policymakers do to increase well-being as a dementia-prevention strategy, but then also when considering the well-being of people living with dementia. I think investing resources into providing supports to families, caregivers, and care partners of people living with dementia to help be able to improve the quality of care that they're receiving and to help them age in place for longer, as well as investing resources into these types of interventions and strategies and environmental enrichments in memory-care facilities to help support the well-being and continued quality of life of people living with dementia.

Dr Sam Moxon:

I think that's a really nice strategy to try, and because it's obviously something that can have a big impact, and so getting it to the people that need it, it's got to be a priority. So, I'd like to ask you all an overarching question now, and that is what you think your next steps could be in your research around this topic of well-being and dementia, and if there's any upcoming studies or projects that you're particularly excited about and would like to tell the audience about.

Dr Emily Willroth:

Absolutely. So, I think one thing that we're really interested in is to better understand these mechanisms, right? We have these theories for why well-being is linked with dementia, but really testing specific biological, social, behavioural mechanisms will help us to better understand the why and will also help us to be able to take the next step into potentially developing and testing well-being-enhancing interventions as a dementia-prevention strategy. And this is important both because it's the next step in causal inference, but it's also the next step in potentially applying these findings in a way that will help prevent dementia and actually be one potential strategy.

In doing that, one thing that's really important to us is to understand how generalizable us are in these different areas, and how well-being may be linked to dementia in diverse populations and how social context might play a role. And Kyrsten and Karysa are actually both doing some really interesting work on that note. So, I'd love to hand things over to Kyrsten next.

Dr Kyrsten Hill:

Thanks, Emily. One way that we're doing this right now in the lab is with a project using coordinated data analysis or CDA, and in the project I'm working on, we're looking at bidirectional relationships between life satisfaction and cognitive functioning and using CDA to look at this across multiple large-scale longitudinal studies from different countries. And so CDA uses meta-analytic techniques so researchers can test the same research question across multiple datasets and then synthesise these results to increase the replicability and generalizability of findings.

And something that's also exciting about this project is it addresses some key questions related to the directionality of the association between well-being and cognition, as well as questions related to how specific types of well-being are related to cognitive functioning. And then I know Karysa is doing some interesting work in this area as well, if you'd like to share, Karysa.

Karysa Britton:

Thanks, Kyrsten. So, another project going on in the lab right now is when using moderation analysis to examine how different sociocultural factors like race, sex, socioeconomic status impacts these associations we see between well-being and dementia risk. So, for example, we can answer questions about whether the association between well-being and dementia are stronger or weaker for males or females, for example. And what we really want to do here is understand who well-being might serve as a protective factor for, and that will allow us to better tailor our potential well-being interventions in the future.

Dr Sam Moxon:

So really casting a wide net to try and look at the bigger picture. That sounds fascinating, and I wish you the best luck with those upcoming studies. So, I'd like to go back to you again, Emily, and ask. So, dementia doesn't really respect geography. It's everywhere in the world, and pretty much every country that's battling dementia in large numbers has some form of organisation that's trying to raise money and raise awareness to individuals so that they could... Because for years, there was a massive misunderstanding of dementia. Oh, it's just a natural part of ageing. That's just what happens when they get older. And we now are thankfully starting to tell people that that's not the case.

And I think this kind of research is also imperative that we get people to understand the importance of this so they can start to integrate it into their daily lives. And so, the question I'm trying to get around to is how you think individuals, but also organisations like, for example, the Alzheimer's Association, can best support and promote research in this area, so not only is the research conducted, but it's communicated to people as well.

Dr Emily Willroth:

Absolutely. I think that there's two main things that individuals and organisations can really do to help support and disseminate research on this topic. The first I think is raising awareness about the importance of mental health and well-being and that our mental well-being is just as important as our physical health, as our cognitive function, as our health behaviours in terms of shaping our overall health trajectories. And I think getting that message out there can really help both to empower individuals to prioritise their mental health, to empower policymakers to make changes that support the mental health of their populations.

The other thing that I think in particular organisations dedicated to dementia research and dementia care can do is to really help lead the way in terms of shifting away from a solely deficit-focused medical model view of dementia to also consider a strengths-based approach that preserves the personhood of people living with dementia and really considers that well-being doesn't stop with a dementia diagnosis. Although, of course, all of us, our goal is to prevent dementia when possible and to develop treatments for individuals living with dementia, in the meantime, we still have millions of people living with dementia, and really understanding that it's still possible to live well and that there's things that we can do in terms of shaping the environments and care, reducing stigma around dementia, I think it's a really important step alongside prevention and treatment research.

Dr Sam Moxon:

Yeah, definitely. And before I come to the final take-home messages, I'd like to also ask what's been the most surprising or rewarding aspect of your research journey so far?

Dr Emily Willroth:

I think one of the most rewarding aspects of my research journey so far, and especially since becoming involved in dementia research, is really recognising and enjoying the value of interdisciplinary collaboration. So, I came into this field a little bit as an outsider and specifically with a background in psychology, but getting to work with epidemiologists, biologists, medical doctors, now increasingly policymakers, to really see how all of these different areas of research and expertise can come together to take on this really big challenge of dementia prevention has been really rewarding for me.

Dr Sam Moxon:

Yeah, definitely, definitely. And so, I'd like to just ask if you could finish with maybe... We've talked about a lot today, so what are you think the final key take-home messages that the audience should take away from this?

Dr Emily Willroth:

I think the key take-home messages, I think from this body of research as a whole, are just understanding the importance of well-being for health as we age, whether that's brain health and cognitive health, but our physical and mental health as well, and that there are things that policymakers can do to help support the well-being of populations, and that in turn, that's going to have a positive downstream effect on lots of different things that our governments care about, that individuals and families care about, and that all of this is going to be increasingly more important as we have a growing older adult population, hopefully.

Dr Sam Moxon:

I definitely concur with that. So, guys, we hope you found that conversation as enlightening as I have. To sum it all up, the World Happiness Report has shown us that happiness and well-being are essential components of a fulfilling life, and this holds true across all ages and all regions. So, from our discussion, we learned that well-being plays a crucial role in dementia prevention and care, and high levels of happiness can act like a protective shield against dementia, making it more than just a feel-good factor. It's basically medicinal. So, Emily, Karysa, and Kyrsten's research has opened up our eyes to the powerful impact of environmental and behavioural strategies in improving the lives of those with dementia. It's not just about extending life but enhancing the quality of life of those precious years, and I think that's really important.

So, let's take a page from this report. Let's embrace happiness, cherish those joyful moments, and spread a little bit more kindness each day. After all, as we've seen, happiness is more than just a state of mind. It's a key ingredient for a healthier, more vibrant life, even in the face of challenges like dementia. So, I'd like to thank our really inspiring guests, Emily, Karysa, and Kyrsten for sharing your invaluable insights. And thank you to our listeners for joining us on this journey. And if you just can't get enough of this topic, please do visit the Dementia Research website. You'll find a full transcript, you'll find biographies of the guests, blogs, much more on the topic. And of course you can find a link to download the report.

I'd like to thank you guys for joining us. It's been a real honour to speak to you. I've learned a lot and I've got a lot of things that I want to research now, so thank you all for joining us. And until next time, keep smiling and keep shining. I'm Dr. Sam Moxon. You've been listening to the Dementia Researcher Podcast, and we'll see you next time.

Voice Over:

The Dementia Researcher Podcast was brought to you by University College London with generous funding from the UK National Institute for Health Research, Alzheimer's Research UK, Alzheimer's Society, Alzheimer's Association, and Race Against Dementia. Please subscribe, leave us a review, and register on our website for full access to all our great resources, dementiaresearcher.nihr.ac.uk.