This is a model answer of Critical Review paper for Malaysian postgraduate examination in psychiatry. This model answer was used for marking the review paper for Master of Medicine (Psychiatry) and Master of Psychological Medicine, May 2009.
Background and Objective: Epilepsy and depression are interlinked and lead to an increased risk of suicidal ideation and suicide. Although depression is a significant risk factor for suicidal ideation in epilepsy patients, epilepsy itself is independently associated with suicidal ideation. There are various other factors related to epilepsy that further increase this risk. Methods: We conducted a study of suicidal-ideation amongst epilepsy patients in our centre. Demographic data and clinical history were obtained while suicidal ideation was determined using the Columbia Suicide Severity Rating Scale (C-SSRS). Beck’s Depression Inventory–II (BDI-II) was used to identify presence of depression. Results: We recruited 80 patients with epilepsy and an equal number of controls. Epilepsy patients were more likely to be depressed with a mean BDI-II score of 9.09 ±6.48 compared to controls who has a mean score of 5.56 ±4.56. The proportion of epilepsy patients with suicidal ideation was 33.75% vs. 5.00% in the control group (p 3 anti-epileptic drugs or prior head surgery. Our findings suggest that assessment of suicidal ideation is pertinent in high-risk epilepsy patients and should be routinely carried out in the clinical setting.
Objective: This case report highlights the issue of hypersexuality in persons with dementia and outlines the possible etiology and challenges associated with interventions of inappropriate sexual behaviors in dementia.
Methods: We report a 75-year-old male with vascular dementia who developed hypersexuality and aggression towards his wife. The management plans are elaborated in this paper.
Results: A combination of pharmacological and psychosocial intervention lead to the resolution of his inappropriate sexual behavior and improvement in his relationships with his wife and children.
Conclusion: Inappropriate sexual behaviors need to be recognized and managed without compromising the fulfillment of the human's basic need of sexuality.
Making a medical diagnosis in an elderly person presenting with first time psychiatric symptoms can be challenging.
A 61 year old lady presented with 4 years history of tactile hallucinations in her legs and delusions of persecution,
and 2 weeks history of depression and mild cognitive impairment. There were no other significant physical findings,
except for dysarthria and fine bilateral hand tremors. As patient had no prior psychiatric history, she was investigated
for differential diagnoses of late-onset schizophrenia, psychotic depression and early dementia. A thorough
investigation for concomitant medical illnesses was done which revealed low serum calcium, high serum phosphate
and relatively low serum parathyroid hormone levels. A diagnosis of Fahr’s syndrome (FS) was made based on
history, hematological findings of idiopathic hypoparathyroidism and bilateral basal ganglia calcifications (BGC)
on neuroimaging. Treatment of FS is non-specific and mainly symptomatic. This patient improved with treatment
comprising antidepressant, antipsychotic and calcium supplement.
Introduction: There are increasing trend in using information and communication technology to enhance the deliverance of reminiscence work for people with dementia. Thus this study aimed to explore the feasibility of Digital Memory Album (DMA) to support reminiscence work and subsequently evaluate the psychosocial benefits of the DMA system for older adults with dementia living in community. Method: This was an exploratory case study involved five participants with mild to moderate dementia and their primary caregivers. Each participant had an opportunity to review their own life history using Life Review Experience Form (LREF) with the researcher for 8 consecutive weeks in which subsequently facilitated in development of a personalised digital life story. Caregivers provided additional information to support the development of DMA. The whole process was audio recorded. The digital life story was presented in multimedia format and displayed using the DMA. The DMA was given to the participants for review. Qualitative data was collected using semi structure questions with the participants and caregivers immediately after the completion of DMA and 6 weeks after having the DMA as a gift. Results: Analysis of the audio-records and interview data indicated that DMA promoted psychosocial wellbeing which included enjoyment, comfort, stimulate long term memory and enhanced communication and social interactions with family members and friends. Caregivers expressed the DMA helped them in recollecting the past and better understanding of their loved ones. It also reoriented their focus on their loved ones from their disability to the remaining strength. Conclusion: For the first time, this study demonstrates the feasibility of using DMA in improving the psychosocial wellbeing for people with dementia in Malaysia.
The goal of this study was to examine the reliability and validity of the Bahasa Malaysia version of the Montreal cognitive assessment (MoCA-BM) and to determine its optimal cut-off score among older adults with mild cognitive impairment (MCI), after adjustments for age, gender, levels of education, physical functioning and depressive symptoms. A total of 2237 community dwelling older adults aged 60 years and above were randomly selected for the study, excluding those with MMSE score below 14. Instruments administered were the MoCA-BM, the Malay Mini-Mental State Examination (MMMSE), the Rey Auditory Verbal Learning Test (RAVLT), the Digit Span and the Digit Symbol subtests of the Wechsler Adult Intelligence Scale (WAIS), activities of daily living (ADL) and the Geriatric Depression Scale (GDS). MCI were determined using the Petersen’s 2014 criteria as the gold standard. SPSS version 22 was used for reliability and validity analysis and optimal cut-off score detection. Cronbach’s α of the MoCA-BM was 0.691 and concurrent validity was high between MoCA-BM and MMMSE scores (r=0.741). Optimal cut-off point for MoCA-BM to detect MCI among older adults in Malaysia was 17/18, with sensitivity of 68.2% and specificity of 61.3%. Using this cut-off, 38.9% of participants were detected to be at risk of MCI. In conclusion, MoCA-BM is a reliable and valid screening instrument for MCI among Malaysian elderly community. The newly derived optimal cut-off for MCI is much lower than the original MoCA with modest ability to discriminate between normal and MCI older adults in the community.
Subclinical hypothyroidism (SHT) is a biochemical diagnosis, defined as an elevated Thyroid Stimulating Hormone (TSH) with normal free thyroxine (FT4). It affects 4-10% of the adult population and is more prevalent in elderly women. Its commonest cause is autoimmune thyroiditis, detected by anti- thyroid peroxidase antibody (TPO-Ab). About 2-5% of SHT patients progress to overt hypothyroidism annually. The SHT prevalence among depressed patients ranges between 3% and 17%. This study aimed to determine the prevalence of SHT and TPO-Ab positivity among patients diagnosed with depressive disorders. It was a cross-sectional study carried out in the Universiti Kebangsaan Malaysia Medical Centre over a 12 months period. Serum TSH, FT4 and TPO-Ab were measured. Results showed that 82% of depressed patients were euthyroid, 4% had SHT, 11% had subclinical hyperthyroidism and 2% had discordant thyroid function. TPO-Ab positivity among the subjects was 7%, one of whom had SHT. In conclusion, the prevalence of SHT and TPO-Ab positivity in the study population, at 4% and 7%, respectively, were comparable to previous findings.
The main objectives in this study were to determine the percentage of psychiatric comorbidity among treatment seeking opioid dependents in Klang Valley. A cross sectional study of opioid dependence patients was conducted between December 2007 and May 2008 at ten community-based drug substitution therapy clinics in Klang Valley. A total of 204 opioid dependence patients participated in the study using the structured clinical interview for DSM-IV Axis I disorders
(SCID-I) as its instruments. The percentage of psychiatric comorbidity among opioid dependents was 43.6%. Major depressive disorder had the highest prevalence at 32.6%, followed by dysthymia at 23.6% and Panic disorder at 14.6%. Psychiatric comorbidity were found to have significant differences (p<0.05) in connection with history of polysubstance abuse, previous history of court sentences (legal status) and family history of psychiatric illnesses. This study showed that the percentage of psychiatric comorbidity is high among the opioid dependents. It highlights the urgent need for the psychiatric comorbidity to be assessed and early intervention is important for this group of patients.
Many studies among caregivers of breast cancer patients have revealed that stress affects a significant proportion of this particular group. The situation among caregivers of breast cancer patients in Malaysia was however not known. This cross-sectional study aimed to determine the proportion of the family caregivers who experienced stress while caring for the breast cancer patients who were on oncologic treatment in Kuala Lumpur Hospital and factors which predict the stress among these caregivers. A total of 130 family caregiver-breast cancer patient dyads who were attending the Institute of Radiotherapy & Oncology, Kuala Lumpur Hospital during a 3-month study period were recruited by non-random sampling method. The caregivers’ stress was measured using the stress domain of the depression, anxiety, stress scale (DASS-21) while other data obtained included the patients’ and caregivers’ socio demographic status, the patients’ illness characteristics and the caregiving factors and the caregivers’ perceived social support. About 1 in 4 (24.6%; n=32) caregivers of breast cancer patients were stressed. Duration of caregiving, sharing of caregiving burden, patients’ age and patients’ functionality were found to be significantly associated with stress (p value <0.05). All these factors, except for duration of caregiving, continue to be significant in the logistic regression analysis (p value <0.05). This study found that a high proportion of the family caregivers experienced stress. Identification of the predictors of stress among the caregivers may help in the prevention strategies of stress in this group of caregivers.
Relatively less comprehensive web based programme has been developed for detecting risk of mild cognitive impairment (MCI) and further impart preventive strategies and lifestyle education. Thus, this study has developed a comprehensive web based programme for early screening of risk of MCI together with education package for preventing MCI known as WESIHAT 2.0. WESIHAT 2.0 is a senior friendly website which has appropriate design interface facilitating access of older people especially with the use of touch-screen technology. WESIHAT 2.0 has incorporated four major components namely TUA WELLNESS screening tool, which is a comprehensive, online based, 10-item screening tool for detecting risk of MCI, 10-guides for preventing MCI, health diary and healthy food. Evaluation of acceptance of WESIHAT 2.0 was done among 71 people which comprised of 30 older people and 30 caregivers, chosen equally based on ethnic composition and 11 health care professionals who has experience working in the field of geriatric and 2 freelance website developer. All older people and caregivers stated that the content of website was very useful for preventing MCI, however, about 36.4% of health professionals stated several improvements needed to be done before releasing the end-product to the users. Comments given were smaller font size (27.3), addition of more pictures (27.3%), using simpler terms (36.4%) and changing certain design for better view of older people (18.2%). Amendments were made based on each comment given and the finalized website were used for a 6-month intervention programme for neuroprotection among older people who failed to achieve successful aging. It is timely for an online based approach for prevention of MCI. WESIHAT 2.0 is the first website in Malaysia which has been accepted by all older people and caregiver and more than half of healthcare professionals to prevent memory decline.
Introduction: This study aimed to identify dietary patterns (DPs) and their
association with successful aging (SA). Methods: A comparative cross-sectional
study was conducted among 579 elderly subjects recruited from four states in
Malaysia through a multistage random sampling method. SA was defined as having
no chronic illnesses, no functional limitation, normal global function, no depression,
a good quality of life and good self-perceived health. Information on dietary intake was
obtained using a diet history questionnaire. Cognitive functions were assessed using
the Mini Mental State Examination (MMSE), depressive symptoms using Geriatric
Depression Score-15 items (GDS-15) and a question regarding their perceived health
and quality of life. Activities of Daily Living (ADL) and Instrumental Activities of Daily
Living (IADL) questionnaires were used to determine functional status. DPs were
obtained using the principal component analysis (PCA) approach. An ordinal logistic
regression model was used to examine associations between DP scores and SA.
Results: Five DPs were identified namely ‘sweet foods-beverages’, ‘meat-vegetablesrice and noodles’, ‘local snacks-fish and seafood-high salt foods’, ‘fruits-legumes’, and
‘tropical fruits-oats’. A higher score for ‘tropical fruits-oats’ DP was associated with
SA [Adjusted OR=1.59 (95% CI: 1.08-2.32)]. However, the association diminished
when the model was adjusted for education level. Further analysis indicated that
this DP increased the chance of SA among those with secondary education and above
[Adjusted OR=2.43 (95% CI: 1.09–5.42)]. Conclusion: ‘Tropical fruits-oats’ DP is
associated with SA among elderly with secondary education and above. There is a
need to investigate DPs among those with lower education.
Simulated/ standardized patients (SPs) have become one of the significant components in today’s medical education and students’ assessment. Some differences exist in the training method of SPs for psychiatry examinations compared to other medical disciplines. This brief report highlights the challenges encountered in the training process and methods to overcome those challenges. A wellstructured, intensive training remains as one of the most important factors in ensuring standardization of SPs for psychiatric examinations.
The aim of this study was to determine the relationships between ApoE genotypes and ‘behavioural and psychological symptoms of dementia’ (BPSD). A cross-sectional study was conducted on 46 outpatients with dementia (aged 60 and above) and their caregivers attending the psychogeriatric clinics at Universiti Kebangsaan Malaysia Medical Centre (UKMMC) and Hospital Kuala Lumpur. Neuropsychiatric Inventory (NPI) was used for the assessment of BPSD. The patients’ blood samples were taken for Apolipoprotein genotyping after consented by the caregivers. There were more female (69.6%) and Chinese (50%) patients with a mean age of 73.7 years. ApoE ε3/ε3 was the most common ApoE allele (60.7%) and mostly found in Chinese patients. ApoE genotype was significantly associated with ethnicity (p=0.03) and marital status (p=0.01). Alzheimer disease was the most common subtype of dementia (41.3%) and the highest carrier of ApoE ε3/ε3 (30.4%). The ApoE ε4/ ε4 scored highest in BPSD median score 44 (17.5 to 90) but the relationships
between ApoE genotypes and subtypes of dementia or BPSD scores were not significant (p=0.20; p=0.64). Agitation was the most common symptom, with delusions showing the highest scores on the NPI with no significant association to ApoE 4 allele. In conclusion, there was no significant relationship between ApoE genotypes and severity or types of BPSD in dementia patients.
Mild cognitive impairment (MCI) is a common condition among the elderly and is believed to be a precursor to Alzheimer disease. This study aims to detect the prevalence of MCI and factors associated with it. A cross-sectional study was conducted on a group of elderly patients attending various medical clinics in Universiti Kebangsaan Malaysia Medical Centre (UKMMC) in 2010. Only patients aged 60 years and above, literate with no hearing or visual impairments were included. Screening instruments included the Mini Mental State Examination (MMSE) and a questionnaire on
sociodemographic and clinical data. The cut-off points for MMSE for MCI was 21/30 to 28/30. The prevalence rate based on MMSE score for ‘normal’ and MCI were 35.3% and 64.7%, respectively. Most of the 346 patients (33.9%) had only one type of medical illness and on one type of medication. MCI was significantly associated with low educational achievement (p<0.05) and rheumatological diseases (p= 0.05). However, it is not associated with the number of medical illnesses suffered by patients and the number of medications prescribed. This study highlighted that MCI was a common condition among the elderly UKMMC Medical clinic attendees and was significantly associated with their low education level.
Introduction Anxiety and depression were known to bring detrimental outcome in patients
with ischemic heart disease (IHD). Notwithstanding their high prevalence
and catastrophic impact, anxiety and depression were unrecognized and
untreated. The aim of this study was to determine the prevalence of anxiety
and depression among IHD patients and the association of this condition with
clinical and selected demographic factors.
Methods This was a cross-sectional study on 100 IHD patients admitted to medical
ward in UKMMC. Patients diagnosed to have IHD were randomly assessed
using Hospital Anxiety and Depression Scale (HADS) and Perceived Social
Support (PSS) Questionnaire. Socio-demographic data were obtained by
direct interview. Fifteen percent of IHD patients in this sample were noted to
have anxiety, fourteen percent noted to have depression while thirty two
percent was noted to have both anxiety and depression. Patients’ age group
and the duration of illness were found to have significant association with
anxiety. Socio-demographic data were obtained by direct interview.
Results Fifteen percent of IHD patients in this sample were noted to have anxiety,
fourteen percent noted to have depression while thirty two percent was noted
to have both anxiety and depression. Patients’ age group and the duration of
illness were found to have significant association with anxiety. The other
clinical and selected demographic factors such as gender, race, marital status,
education level, occupation, co-existing medical illness and social support
were not found to be significantly associated with anxiety or depression
among the IHD patients.
Conclusions In conclusion, proper assessment of anxiety and depression in IHD patients,
with special attention to patients’ age and duration of illness should be
carried out routinely to help avert detrimental consequences.
BACKGROUND AND AIM:
Focus on screening for cognitive impairment has to be given particular importance because of the rising older adult population. Thus, this study aimed to develop and assess a brief screening tool consisting of ten items that can be self-administered by community dwelling older adults (TUA-WELLNESS).
METHODOLOGY:
A total of 1,993 noninstitutionalized respondents aged 60 years and above were selected for this study. The dependent variable was mild cognitive impairment (MCI) assessed using neuropsychological test batteries. The items for the screening tool comprised a wide range of factors that were chosen mainly from the analysis of ordinal logistic regression (OLR) and based on past literature. A suitable cut-off point was developed using receiver operating characteristic analysis.
RESULTS: A total of ten items were included in the screening tool. From the ten items, eight were found to be significant by ordinal logistic regression and the remaining two items were part of the tool because they showed strong association with cognitive impairment in previous studies. The area under curve (AUC), sensitivity, and specificity for cut-off 11 were 0.84%, 83.3%, and 73.4%, respectively.
CONCLUSION: TUA-WELLNESS screening tool has been used to screen for major risk factors of MCI among Malaysian older adults. This tool is only suitable for basic MCI risk screening purpose and should not be used for diagnostic purpose.
KEYWORDS: TUA-WELLNESS; mild cognitive impairment; screening; sensitivity; specificity