R.P. and R.H. are atheists. C.C.H.C. is an ordained Anglican and a past Chair of the Royal College of Psychiatrists Spirituality and Psychiatry Special Interest Group. He writes here in a personal capacity.

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Self-harm is a major public health concern. Increasing ageing populations and high risk of suicide in later life highlight the importance of identification of the particular characteristics of self-harm in older adults.

To systematically review characteristics of self-harm in older adults.

A comprehensive search for primary studies on self-harm in older adults was conducted in e-databases (AgeLine, CINAHL, PsycINFO, MEDLINE, Web of Science) from their inception to February 2018. Using predefined criteria, articles were independently screened and assessed for methodological quality. Data were synthesised following a narrative approach. A patient advisory group advised on the design, conduct and interpretation of findings.

A total of 40 articles (n = 62 755 older adults) were included. Yearly self-harm rates were 19 to 65 per 100 000 people. Self-poisoning was the most commonly reported method. Comorbid physical problems were common. Increased risk repetition was reported among older adults with self-harm history and previous and current psychiatric treatment. Loss of control, increased loneliness and perceived burdensome ageing were reported self-harm motivations.

Self-harm in older adults has distinct characteristics that should be explored to improve management and care. Although risk of further self-harm and suicide is high in all age cohorts, risk of suicide is higher in older adults. Given the frequent contact with health services, an opportunity exists for detection and prevention of self-harm and suicide in this population. These results are limited to research in hospital-based settings and community-based studies are needed to fully understand self-harm among older adults.

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In response to increasing numbers of older people in general hospitals who have cognitive impairment such as dementia and delirium, many hospitals have developed education and training programmes to prepare staff for this area of clinical practice.

To review the evidence on educational interventions on hospital care for older people with cognitive impairment.

A mixed methods systematic review and narrative synthesis was undertaken. The following electronic databases were searched: Medline, Embase, CINAHL, PsycINFO, EBM Reviews, ASSIA and Scopus, as well as Health Management Information Consortium (HMIC), ProQuest, PubMed and SCIE: Social Care Online. Initial searches were run in August 2014 (update search September 2016). Titles and abstracts of studies retrieved were screened independently. The full text of eligible studies were then independently assessed by two review team members. All included studies were assessed using a standard quality appraisal tool.

Eight studies relating to delirium, six on dementia and two on delirium and dementia were included, each testing the use of a different educational intervention. Overall, the quality of the studies was low. In relation to delirium, all studies reported a significant increase in participants' knowledge immediately post-intervention. Two of the dementia studies reported an increase in dementia knowledge and dementia confidence immediately post-intervention.

The variety of outcomes measured makes it difficult to summarise the findings. Although studies found increases in staff knowledge, there is insufficient evidence to conclude that educational interventions for staff lead to improved patient outcomes.

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Shared decision-making is advocated but may be affected by cognitive impairment. Measures of shared decision-making provide global descriptions of communication without detailed analysis of the subtle ways in which doctors invite patient input.

We aimed to explore medication decisions in dementia, using a standardised Treatment Recommendation Coding Scheme.

We analysed 71 video-recorded dementia diagnostic meetings from nine memory clinics. Recommendations were coded as pronouncements (‘I will start you on medication’), proposals (‘Shall we try medication?’), suggestions (‘Would you like to try medication?’), offers (‘I can prescribe medication’) or assertions (‘There is medication’). Patient responses were coded as acceptance (‘I'd like to have that’), active resistance (‘I'm not very keen’) and passive resistance (minimal or no response). Cognitive test scores, prescription rates and satisfaction were assessed and associations were explored.

Doctors used suggestions in 42% of meetings, proposals in 25%, assertions in 13%, pronouncements in 11% and offers in 9%. Over 80% of patients did not indicate clear acceptance. Patients were most likely to actively resist after suggestions. There was no association between cognitive impairment and recommendation format. Patients were less satisfied with pronouncements. Patient preference did not influence whether medication was prescribed.

Doctors initially nominate people with dementia as the decision maker, and this is unaffected by cognitive impairment. Over 80% of patients resisted starting medication, mostly through passive resistance, the most common form of disagreement in communication. Medication still tended to be prescribed, indicating that factors other than patient preference affect prescription.

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Late-life depression (LLD) is a disabling disorder and antidepressants are ineffective in as many as 60% of cases. Converging evidence shows a strong correlation between LLD and subsequent risk of cardiovascular disease. There is a need for new, well-tolerated, non-pharmacological augmentation interventions that can treat depressive symptoms as well as improve heart rate variability (HRV), an important prognostic marker for development of subsequent cardiovascular disease. Meditation-based techniques are of interest based on positive findings in other samples.

We aimed to assess the efficacy of Sahaj Samadhi meditation (SSM), an underevaluated, standardised and manualised meditation intervention, on HRV and depressive symptoms.

Eighty-three men and women aged 60–85 years, with mild to moderate depression and receiving treatment as usual (TAU) were randomised to either the SSM or TAU arm. Those allocated to SSM attended 4 consecutive days of group meditation training, using personalised mantras followed by 11 weekly reinforcement sessions. HRV and Hamilton Rating Scale for Depression (HRSD; 17-item) score were measured at baseline and 12 weeks.

All time and frequency domain measures of HRV did not significantly change in either arm. However, there was significant improvement in the SSM arm, compared with TAU, on the HRSD (difference in mean, 2.66; 95% CI 0.26–5.05; P = 0.03).

Compared with TAU, SSM is associated with improvements in depressive symptoms but does not significantly improve HRV in patients with LLD. These results need to be replicated in subsequent studies incorporating a group-based, active control arm.

R.I.N. is the Director of Research and Health Promotion for the Art of Living Foundation, Canada and supervised the staff providing Sahaj Samadhi meditation. S.R. has received research funding from Satellite Healthcare for a mindfulness meditation trial in patients on haemodialysis. The remaining authors report no financial or other relationship relevant to the subject of this article.

There is a recognised need for the identification of factors that might be protective against the development of depression in older adults. Over the past decade, there has been growing research demonstrating the effects of cultural engagement (which combines a number of protective factors including social interaction, cognitive stimulation and gentle physical activity) on the treatment of depression, but as yet not on its prevention.

To explore whether cultural engagement in older adults is associated with a reduced risk of developing depression over the following decade.

Working with data from 2148 adults in the English Longitudinal Study of Ageing who were free from depression at baseline, we used logistic regression models to explore associations between frequency of cultural engagement (including going to museums, theatre and cinema) and the risk of developing depression over the following 10 years using a combined index of the Centre for Epidemiological Studies Depression Scale (CES-D) and physician-diagnosed depression.

There was a dose–response relationship between frequency of cultural engagement and the risk of developing depression independent of sociodemographic, health-related and social confounders. This equated to a 32% lower risk of developing depression for people who attended every few months (odds ratio (OR) = 0.68, 95% CI 0.47–0.99, P = 0.046) and a 48% lower risk for people who attended once a month or more (OR = 0.52, 95% CI 0.34–0.80, P = 0.003). Results were robust to sensitivity analyses exploring reverse causality, subclinical depressive symptoms and alternative CES-D thresholds.

Cultural engagement appears to be an independent risk-reducing factor for the development of depression in older age.

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Deficits in frontal lobe perfusion have been demonstrated in late-life depression; however, studies to date have generally involved small numbers, used neuroimaging rather than bedside testing and have not controlled for important covariates.

We aimed to examine the association between depressive symptoms and frontal lobe perfusion during standing, in a large cohort of community-dwelling older people.

Participants aged ≥50 years underwent continuous measurement of orthostatic blood pressure by finometry, and frontal lobe perfusion by near-infrared spectroscopy. Depressive symptoms were assessed by the eight-item Centre for Epidemiological Studies Depression Scale. Real-time frontal lobe cerebral oxygenation was measured by the Portalite System, detecting changes in frontal lobe perfusion and reporting a tissue saturation index score.

Almost 8% (209 out of 2616) had clinically significant depressive symptoms. Multilevel models demonstrated a significantly lower tissue saturation index in participants with depressive symptoms at both 60 and 90 s post-stand, with coefficients of −0.43 (95% CI −0.63 to −0.22) and −0.37 (95% CI −0.57 to −0.16), respectively. Controlling for relevant covariates did not significantly attenuate these associations. After addition of systolic blood pressure this association was no longer significant, suggesting lower blood pressure may modify this relationship.

This study demonstrates that lower frontal lobe perfusion, related to lower values of baseline systolic blood pressure, is associated with clinically significant depressive symptoms in a cohort of community-dwelling older people. Given the recognised longitudinal association between lower blood pressure and depression in older people, this may represent a potential therapeutic target for prevention of incident depression.

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