Psychiatric epidemiology: a problem of standardisation
In order to reliably track states of health in populations, looking foremerging patterns and trends, one must be able to define exposuresand outcomes of interest in a standardised way. All diseases can be
nosologically classified, each with their ‘reference
definitions. However, where these conditions are psychiatricsyndromes, the reference-standard is necessarily a set of clinicallyagreed descriptions of psychopathology rather than any objectivequantities.
There are two different approaches for neuropsychiatric definitions,the International Classification of Diseases (World HealthOrganization) and the Diagnostic and Statistical Manual of MentalDisorders (American Psychiatric Association). There are somedifferences between these two systems (see references for adiscussion on how these might affect case-ascertainment in dementia
). However, both are subject to common problems.Firstly, these definitions are not stable over time (ICD-9 vs 10, DSM-III-R vs DSM-IV, with further iterations in evolution). Nor are thesedefinitions easily transferrable across cultural contexts. Yet moreproblematic is that these clinical criteria have the potential to vary,and so can be interpreted differently by different clinicians. Anexample is how the definition might be applied to persons of different ages depending on the expectations of normality for that age group. Inother words, the threshold for abnormal cognitive or functionalimpairment may decrease with age, in line with a belief that someimpairment is to a degree expected (and therefore not abnormal) inolder age.
Finally, in the research setting, a core problem is how tooperationalise these criteria so that case-ascertainment can beachieved in a consistent manner.Underlying these difficulties is the problem of how to agree theboundaries for a spectrum of psychiatric symptoms. While there isrelatively little disagreement about moderate and severe dementia,studies that include milder cognitive deficits lead to much lessconsistent estimates of prevalence (see references for review
). Mildcognitive impairment (MCI) has been regarded to be of possiblerelevance to dementia, but applying the MCI construct to population-based cohorts has not been straightforward.
The equivalent entityin delirium
i.e. subsyndromal delirium
also needs to be consideredin light of these issues.
Dementia epidemiology: some approaches
Dementia is clinically defined by identifying progressive deficits intwo or more cognitive domains sufficient to impair function inactivities of daily living. Three population-based studies can be usedas examples to illustrate the different ways in which this definition hasbeen operationalised in the context of research (Table 1). Vantaa 85+