Indian Psychiatric Society multicentre study: Diagnostic patterns, comorbidity and prescription practices for patients with Dementia

BACKGROUND

There are more than 5 million people with dementia in India. Multicentre studies looking at details of treatment for people with dementia In India are lacking. Clinical audit is a quality improvement process which aims to systematically assess, evaluate, and improve patient care. Evaluating current practice is the key to a clinical audit cycle.

AIM

This study aimed to assess the diagnostic patterns and prescribing practices of psychiatrists for patients with dementia in India.

METHOD

A retrospective case file study was conducted across several centers in India.

RESULTS

Information from the case records of 586 patients with dementia was obtained. Mean age of the patients was 71.14 years (standard deviation = 9.42). Three hundred twenty one (54.8%) were men. Alzheimer's disease (349; 59.6%) was the most frequent diagnosis followed by vascular dementia (117; 20%). Three hundred fifty five (60.6%) patients had medical disorders and 47.4% patients were taking medications for their medical conditions. Eighty one (69.2%) patients with vascular dementia had cardiovascular problems. Majority of the patients (524; 89.4%) were on medications for dementia. Most frequently prescribed treatment was Donepezil (230; 39.2%) followed by Donepezil-Memantine combination (225; 38.4%). Overall, 380 (64.8%) patients were on antipsychotics. Quetiapine (213, 36.3%) was the most frequently used antipsychotic. Overall, 113 (19.3%) patients were on antidepressants, 80 (13.7%) patients were on sedatives/hypnotics, and 16 (2.7%) patients were on mood stabilizers. Three hundred nineteen (55.4%) patients and caregivers of 374 (65%) patients were receiving psychosocial interventions.

CONCLUSIONS

Diagnostic and prescription patterns in dementia which emerged from this study are comparable to other studies both nationally and internationally. Comparing current practices at individual and national levels against accepted guidelines, obtaining feedback, identifying gaps and instituting remedial measures help to improve the standard of care provided.

Is Thalamic Lesion a Contributing Factor for Inappropriate Sexual Behavior in Older Adults with Cognitive Impairment?

Thalamus is a group of nuclei located deep inside the brain, well known for its sensory and cognitive functions. However, its role in the reward and behavior regulation is less explored. In this case series, we have presented four cases with inappropriate sexual behaviors (ISB) that are temporally related to thalamic infarction. We have discussed about the limbic part of thalamus and its extensive connections with other regions in regulating sexual behaviors. Although in all the four cases described there was underlying cognitive impairment that can itself increase the risk of ISB, there was potential contributing role of thalamic lesions.

Extension for Community Healthcare Outcomes Based Telementoring of Physicians for Dementia-Effectiveness in India

OBJECTIVE

The study aimed to evaluate the effectiveness of a program based on the telementoring model [Extension for Community Healthcare Outcomes (ECHO)] for primary care physicians in diagnosing and treating patients with dementia.

METHOD

The ECHO model was adapted through 12 live sessions of 2 h every 2 weeks consisting of a didactic presentation by the expert, peer-led new case discussions, and follow-up discussions. In addition, there were 10 h of self-paced e-learning and interim assignments. The impact was examined by noting participation, session ratings, monthly clinical reports, and comparing knowledge and competency scores before and after the course.

RESULTS

Among the 63 participants, 39.7% attended at least 80% of the sessions; completing the program successfully. The ratings for all sessions ranged from "good" to "excellent." The paired sample t-test revealed a statistically significant improvement (p < 0.001) in self-rated skills and confidence in diagnosing and treating dementia with an effect size of 1.25 and 1.37, respectively. No change in the knowledge score was observed throughout the course. A considerable increase in dementia-related clinical practice was observed during four monthly summary of clinical cases. Due to the limited data of monthly reports during the COVID pandemic, no statistical analysis was attempted.

CONCLUSION

The ECHO model appears to have a positive immediate impact on the clinical ability of primary care physicians to diagnose and treat dementia. Its direct impact on patient health and at the community level should be aimed at in future studies.

Multilingualism and semantic dementia - A case report

Language is a vital component of cognition essential for communication. Proficiency in more than one language has become a norm for many in the current era of globalisation. In neurogenerative conditions decline in language ability leads to early dependency. Studies have reported higher cognitive reserve in multilingual compared to monolinguals. Determining preserved language skills in a patient presenting with cognitive concerns helps in understanding the cognitive reserve, early signs of dementia, the extent of impairment due to language deficits and planning for cognitive stimulation. In this article, we have described an elderly woman with multilinguistic abilities who presented with semantic dementia.

The National Mental Health Survey of India (2016): Prevalence, socio-demographic correlates and treatment gap of mental morbidity

BACKGROUND

Recognizing the need for good quality, scientific and reliable information for strengthening mental health policies and programmes, the National Mental Health Survey (NMHS) of India was implemented by National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, in the year 2015-2016.

AIM

To estimate the prevalence, socio-demographic correlates and treatment gap of mental morbidity in a representative population of India.

METHODS

NMHS was conducted across 12 Indian states where trained field investigators completed 34,802 interviews using tablet-assisted personal interviews. Eligible study subjects (18+ years) in households were selected by a multi-stage, stratified, random cluster sampling technique. Mental morbidity was assessed using MINI 6. Three-tier data monitoring system was adopted for quality assurance. Weighted and specific prevalence estimates were derived (current and lifetime) for different mental disorders. Mental morbidity was defined as those disorders as per the International Statistical Classification of Diseases, Tenth Revision Diagnostic Criteria for Research (ICD-10 DCR). Multivariate logistic regression was conducted to examine risk for mental morbidity by different socio-demographic factors. Survey was approved by central and state-level institutional ethical committees.

RESULTS

The weighted lifetime prevalence of 'any mental morbidity' was estimated at 13.67% (95% confidence interval (CI) = 13.61, 13.73) and current prevalence was 10.56% (95% CI = 10.51, 10.61). Mental and behavioural problems due to psychoactive substance use (F10-F19; 22.44%), mood disorders (F30-F39; 5.61%) and neurotic and stress-related disorders (F40-F48; 3.70%) were the most commonly prevalent mental morbidity in India. The overall prevalence was estimated to be higher among males, middle-aged individuals, in urban-metros, among less educated and in households with lower income. Treatment gap for overall mental morbidity was 84.5%.

CONCLUSION

NMHS is the largest reported survey of mental morbidity in India. Survey estimated that nearly 150 million individuals suffer from one or the other mental morbidity in India. This information is to be used for planning, delivery and evaluating mental health programming in the country.

Barriers to Disclosure of Intimate Partner Violence among Female Patients Availing Services at Tertiary Care Psychiatric Hospitals: A Qualitative Study

Background:

Intimate partner violence (IPV)/domestic violence is one of the significant public health problems, but little is known about the barriers to disclosure in tertiary care psychiatric settings.

Methodology:

One hundred women seeking inpatient or outpatient services at a tertiary care psychiatric setting were recruited for study using purposive sampling. A semi-structured interview was administered to collect the information from women with mental illness experiencing IPV to know about their help-seeking behaviors, reasons for disclosure/nondisclosure of IPV, perceived feelings experienced after reporting IPV, and help received from the mental health professionals (MHPs) following the disclosure of violence.

Results:

The data revealed that at the patient level, majority of the women chose to conceal their abuse from the mental health-care professionals, fearing retaliation from their partners if they get to know about the disclosure of violence. At the professional level, lack of privacy was another important barrier for nondisclosure where women reported that MHPs discussed the abuse in the presence of their violent partners.

Conclusion:

The findings of the study brought out the need for mandatory screening of violence and designing tailor-made multicomponent interventions for mental health care professionals at psychiatric setting in India.

Psychological morbidity after job retirement: A review

Retirement from work is usually an inevitable and significant social life event for many elderly. The retirement age is generally around 60 years. It can have negative or positive effect in old age depending on other factors such as frailty, slowing cognitive functions, multiple physical health problems, medications and sensory impairment. The objective of the study is to discuss psychological morbidity in persons following retirement in Indian context. Previous studies indicate possible cross-cultural differences with conflicting findings of positive and negative impact on mental health following retirement in the developed countries. Few available Indian studies on this topic suggest lower self-esteem, low mood, physical health and financial insecurity as mental health consequences following retirement. There is need for prospective studies from India to evaluate the impact of retirement on psychological morbidity as well as the role of related social factors, as the effects on mental health post retirement is more likely to be culture specific.

Clozapine use in geriatric patients- Challenges

Clozapine is the first second generation antipsychotic with different receptor profile of action. Clozapine is the most efficacious drug for the treatment of psychotic disorder and is the drug of choice in treatment resistant schizophrenia. Clozapine is used in elderly patients infrequently owing to its adverse effects profile and tolerability. There is paucity of literature with respect to clozapine use in late life. In this narrative review, we discuss clozapine use in elderly and challenges associated with its use.

Group intervention for carers of geriatric patients: experiences from a clinic in India

Sixty per cent of the global elderly population live in low-and middle-income countries, and this proportion was expected to rise to 70% by 2010 (International Institute of Ageing, 2001; Ferri et al, 2005). The 2001 Indian census found over 70 million people aged 60 years or more (considered senior citizens according to the Indian National Policy on Older Persons). Most of those senior citizens live with younger family members and are dependent on them for financial and social support. Hence, any physiological and psychological changes in the older family members affect the younger supportive members as well.

A study of structural and functional connectivity in early Alzheimer's disease using rest fMRI and diffusion tensor imaging

BACKGROUND/OBJECTIVES

Alzheimer's disease (AD) is a progressive neurodegenerative condition where in early diagnosis and interventions are key policy priorities in dementia services and research. We studied the functional and structural connectivity in mild AD to determine the nature of connectivity changes that coexist with neurocognitive deficits in the early stages of AD.

METHODS

Fifteen mild AD subjects and 15 cognitively healthy controls (CHc) matched for age and gender, underwent detailed neurocognitive assessment and magnetic resonance imaging (MRI) of resting state functional MRI (rs-fMRI) and diffusion tensor imaging (DTI). Rest fMRI was analyzed using dual regression approach and DTI by voxel wise statistics.

RESULTS

Patients with mild AD had significantly lower functional connectivity (FC) within the default mode network and increased FC within the executive network. The mild AD group scored significantly lower in all domains of cognition compared with CHc. But fractional anisotropy did not significantly (p < 0.05) differ between the groups.

CONCLUSION

Resting state functional connectivity alterations are noted during initial stages of cognitive decline in AD, even when there are no significant white matter microstructural changes.

Supportive CSF biomarker evidence to enhance the National Institute on Aging-Alzheimer's Association criteria for diagnosis of Alzheimer's type dementia--a study from Southern India

The present study was undertaken to validate the measurement of biomarkers as a supplement to the latest diagnostic criteria for Alzheimer disease (AD) dementia by National Institute on Aging-Alzheimer's Association (NIA-AA) work group using a sample attending a tertiary care center in Southern India. A total of 20 subjects diagnosed clinically as Alzheimer's dementia according to the NIA-AA criteria for AD were included in the study. The CSF biomarkers Aβ42, t-tau, and p-tau181 were assessed. The biomarker results were compared among mild and moderate to severe AD as defined in the NIA-AA work group guidelines. The results revealed that the amount of Aβ42 was very low in all the 20 samples (<50pg/ml) collected from mild AD cases with CDR score of 1 (n=8), and moderate to severe AD cases with CDR >1 (n=12). t-tau and p-tau levels were in the range of 39.45±5.09pg/ml and 13.06±7.32pg/ml for CDR 1 group. t-tau and p-tau levels were in the range of 49.9±11.28pg/ml and 33.94±15.13pg/ml for moderate to severe cases. Analysis of the data revealed statistically significant differences in the p-tau/t-tau ratio and p-tau/Aβ ratio between CDR 1and CDR >1 AD cases (p<0.001) suggesting that p-tau/t-tau and p-tau/Aβ ratio are good indicators of severity of dementia with discriminative value in differentiating mild AD from moderate to severe AD.

Randomized clinical trial of yoga-based intervention in residents from elderly homes: Effects on cognitive function

CONTEXT

Elderly have increased risk for cognitive impairment and dementia. Yoga therapy may be helpful in elderly to improve cognitive function.

AIMS

We examined the benefits of yoga-based intervention compared with waitlist control group on cognitive function in the residents of elderly homes.

SETTINGS AND DESIGN

Single blind controlled study with block randomization of elderly homes.

MATERIALS AND METHODS

Study sample included yoga group (n=62) and waitlist group (n=58). A total of 87 subjects (yoga=44, waitlist=43) completed the study period of 6 months. Yoga group received daily yoga sessions for 1 month, weekly until 3(rd) month and encouraged to continue unsupervised until 6 months. They were assessed on Rey's Auditory Verbal Learning Test (RAVLT), Rey's complex figure test (CFT), Wechsler's Memory Scale (WMS)-digit and spatial span, Controlled Oral Word Association (COWA) test, Stroop Color Word Interference Test and Trail Making Test A and B at baseline and at the end of 6(th) month.

STATISTICAL ANALYSIS

Paired t-test and analysis of covariance (ANCOVA) to compare the difference in neuropsychological test scores.

RESULTS

Yoga group showed significant improvement in immediate and delayed recall of verbal (RAVLT) and visual memory (CFT), attention and working memory (WMS-spatial span), verbal fluency (COWA), executive function (Stroop interference) and processing speed (Trail Making Test-A) than waitlist group at the end of 6 months after correcting for corresponding baseline score and education.

CONCLUSION

Yoga based-intervention appears beneficial to improve several domains of cognitive function in elderly living in residential care homes. Study findings need to be interpreted after considering methodological limitations like lack of active comparison group.

Effects of yoga intervention on sleep and quality-of-life in elderly: A randomized controlled trial

CONTEXT

Yoga as a life-style practice has demonstrated beneficial effects. The role of yoga in the elderly for such benefits merits investigation.

AIMS

The aim of this study is to examine the effects of yoga intervention on quality-of-life (QOL) and sleep quality in the elderly living in old age homes.

SETTINGS AND DESIGN

Single blind controlled study with block randomization of elderly homes.

MATERIALS AND METHODS

A total of 120 subjects from nine elderly homes were randomized in to yoga group (n=62) and waitlist group (n=58). Subjects in the yoga group were given yoga intervention daily for 1 month and weekly until 3 months and were encouraged to practice yoga without supervision until for 6 months. Subjects in waitlist group received no intervention during this period. Subjects were evaluated with World Health Organization Quality of Life (WHOQOL)-BREF for measuring QOL and Pittsburgh Sleep Quality Index for sleep quality in the baseline and after 6 months.

STATISTICAL ANALYSIS

Independent t-test and repeated measures analysis of covariance respectively was used to measure the difference in outcome measures between the two groups at baseline and after the study period.

RESULTS

Subjects in the yoga group had significantly higher number of years of formal education. Subjects in the yoga group had significant improvement in all the domains of QOL and total sleep quality after controlling for the effect of baseline difference in education between the two groups.

CONCLUSION

Yoga intervention appears to improve the QOL and sleep quality of elderly living in old age homes. There is a need for further studies overcoming the limitations in this study to confirm the benefits of yoga for elderly in QOL and sleep quality.

ApoE4 and late onset depression in Indian population

OBJECTIVE

ApoE4 is a 'risk factor' for cognitive disorders like Alzheimer's dementia, and Late Onset Depression (LOD) is a forerunner of dementia. There is thus a need to study the association between ApoE4 allele and LOD.

METHOD

The study assessed the frequency of ApoE4 allele in 31 cases of LOD above the age of 50 years and 31 matched controls. The subjects were assessed on various clinical parameters towards diagnosis.

RESULTS

There was a significant association between the ApoE4 allele and LOD in comparison to controls (Odd's ratio=4.7, Confidence Interval=1.12 to 19.79, P=0.035). ApoE4 allele had no association with the age of onset of depression, cognitive functions and severity of LOD.

CONCLUSION

Individuals with LOD have a significantly higher frequency of the ApoE4 allele. In other words, elderly in India with an ApoE4 allele have 4.7 times more risk of developing depression in old age. Within LOD group there is no difference between those with and without ApoE4 accordingly in age of onset of depression, cognitive functions and severity of LOD.

Group intervention for carers of geriatric patients: experiences from a clinic in India

Sixty per cent of the global elderly population live in low-and middle-income countries, and this proportion was expected to rise to 70% by 2010 (International Institute of Ageing, 2001; Ferri et al, 2005). The 2001 Indian census found over 70 million people aged 60 years or more (considered senior citizens according to the Indian National Policy on Older Persons). Most of those senior citizens live with younger family members and are dependent on them for financial and social support. Hence, any physiological and psychological changes in the older family members affect the younger supportive members as well.

Clinical practice with antidementia and antipsychotic drugs: Audit from a geriatric clinic in India

BACKGROUND

Dementia is one of the most disabling disorders afflicting the elderly, with a staggering emotional and economic impact. Antidementia agents have been used for delaying cognitive decline. Antipsychotics are commonly prescribed for behavioral symptoms associated with dementia.

OBJECTIVES

To explore the use of anti-dementing agents and antipsychotics used in patients with a diagnosis of dementia Materials and Methods: A retrospective chart review method; geriatric clinic of tertiary care setting.

RESULTS

The study sample included 51 consecutive patients with a diagnosis of dementia. The commonest subtype of dementia that was diagnosed was Alzheimer's disease (45%), followed by Frontotemporal dementia (25%).The commonest antidementia drug that was used was donepezil, which alone was prescribed in 27 patients (52%). The commonest antipsychotic used was quetiapine, which was used in 24 patients (47%).

CONCLUSIONS

The study found donepezil to be the most commonly prescribed antidementia drug and quetiapine to be the most commonly used antipsychotic in a tertiary care geriatric clinic, in a developing country. There is a need to study the cost-effectiveness of antidementia and antipsychotic drugs in patients with dementia, in developing countries.