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   Table of Contents - Current issue
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July-December 2019
Volume 6 | Issue 2
Page Nos. 35-107

Online since Thursday, February 20, 2020

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EDITORIAL  

Multimorbidity in the elderly: Are we prepared for it! p. 35
Sandeep Grover
DOI:10.4103/jgmh.jgmh_1_20  
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IAGMH AWARD PAPER Top

Attitude toward psychotropic medications: A comparison of the elderly and adult patients with affective and psychotic disorders p. 38
Sandeep Grover, Aseem Mehra, Subho Chakrabarti, Ajit Avasthi
DOI:10.4103/jgmh.jgmh_36_19  
Background: Attitude toward psychotropic medications influences medication adherence. Although there are some data on attitude toward psychotropics among the adult patients, there is a lack of data on attitude of elderly patients toward psychotropic medications. Aim: The study aimed to evaluate the attitude of elderly patients toward psychotropic medications and compare the same with adult patients. Materials and Methodology: Attitude toward psychotropic medications of 102 elderly patients and 499 adult patients diagnosed with affective or psychotic disorders were compared using self-report attitude toward psychotropic medications questionnaire. Results: Compared to adult participants, higher proportion of elderly patients considered psychotropic medications to be the most effective way to treat mental illness and believed that psychotropics are a better option for treatment of mental illnesses than alternative treatments. Compared to adults, significantly lower proportion of the elderly believed that psychotropics do not cure but can lead to substantial improvement. In terms of negative attitude toward psychotropic medications, compared to adult participants, significantly higher proportion of the elderly believed that psychotropics are unnatural and poisonous substances which are harmful; psychotropics are just sedatives, which only calm down the patients; in long-run psychotropics worsen the illness; psychotropics can make the body unnaturally hot or cold; are expensive; make the subjects weak and enervated, and it is always better to take less than the prescribed dose of these medications. Compared to adults, elderly patients had significantly higher negative attitude subscale score. Conclusion: Compared to adult patients with affective and psychotic disorders, elderly patients have more negative attitude toward psychotropic medications. Hence, clinicians managing elderly patients should always evaluate the negative attitudes of the elderly toward psychotropic medications and try to address the same, to improve the medication adherence and outcome.
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ORIGINAL ARTICLES Top

Look for the “Treatables” among dementias: It is lifesaving: An experience from a tertiary care center in India in the past 5 years p. 46
Sadanandavalli Retnaswami Chandra, Nitin Ramanujam Chakravarthula, Vani Santosh, Pooja Mailankody, Mahammad Samim Mondal, Dhananjaya I Bhat, CS Vidhya Annapoorni, S Narendiran, Praveen P Sharma, Debjyoti Dhar, Naga V Sai Sudha Gorthi
DOI:10.4103/jgmh.jgmh_28_19  
Context: The aim is to awaken our colleagues to these reversible conditions. These are live saving if understood properly are life saving for patients. That is the purpose of this article and discussed in introduction. Aim: The aim of this study is to identify possible treatable causes in patients who present with progressive cognitive decline. These patients can be identified only by high degree of suspicion, thorough clinical examination and appropriate choosing of case-based investigations. This will be highly rewarding to the patients, their family, and to the treating physician. In this article, we are sharing our experience with the treatable dementias identified which were masquerading as degenerative. Settings and Design: Retrospective study. Subjects and Methods: Retrospective study of patients seen by the authors in the past 5 years who had all the mandatory recommended investigation done was included. Patients who qualified for pseudo-dementia and small vessel disease were not included in the analysis. Statistical Analysis Used: Basic statistical elements only were used as cases in each category are small. Results: Of 1105 patients, 92 had confirmed reversible cause. Among the treatable group immune-mediated dementia formed the largest and constituted about 45.6% followed by infections 19.5%, nutritional 15.2%, and rest were by rare conditions such as Whipple's disease, cerebrotendinious xanthamatosis, mitochondrial disorders, primary demyelination, central nervous system (CNS) lymphoma, surgical conditions such as normal pressure hydrocephalus and subdural hematoma. Conclusion: About 12.1% percentage of patients with memory complaint has a reversible cause which when detected early, the quality of life of both the patient and caregiver are significantly improved. Apart from protocol-based categorization of the patients, individualized thorough clinical examinations are mandatory to identify these patients.
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Look for the “Treatables” among dementias: It is lifesaving: An experience from a tertiary care center in India in the past 5 years p. 46
Sadanandavalli Retnaswami Chandra, Nitin Ramanujam Chakravarthula, Vani Santosh, Pooja Mailankody, Mahammad Samim Mondal, Dhananjaya I Bhat, CS Vidhya Annapoorni, S Narendiran, Praveen P Sharma, Debjyoti Dhar, Naga V Sai Sudha Gorthi
DOI:10.4103/jgmh.jgmh_28_19  
Context: The aim is to awaken our colleagues to these reversible conditions. These are live saving if understood properly are life saving for patients. That is the purpose of this article and discussed in introduction. Aim: The aim of this study is to identify possible treatable causes in patients who present with progressive cognitive decline. These patients can be identified only by high degree of suspicion, thorough clinical examination and appropriate choosing of case-based investigations. This will be highly rewarding to the patients, their family, and to the treating physician. In this article, we are sharing our experience with the treatable dementias identified which were masquerading as degenerative. Settings and Design: Retrospective study. Subjects and Methods: Retrospective study of patients seen by the authors in the past 5 years who had all the mandatory recommended investigation done was included. Patients who qualified for pseudo-dementia and small vessel disease were not included in the analysis. Statistical Analysis Used: Basic statistical elements only were used as cases in each category are small. Results: Of 1105 patients, 92 had confirmed reversible cause. Among the treatable group immune-mediated dementia formed the largest and constituted about 45.6% followed by infections 19.5%, nutritional 15.2%, and rest were by rare conditions such as Whipple's disease, cerebrotendinious xanthamatosis, mitochondrial disorders, primary demyelination, central nervous system (CNS) lymphoma, surgical conditions such as normal pressure hydrocephalus and subdural hematoma. Conclusion: About 12.1% percentage of patients with memory complaint has a reversible cause which when detected early, the quality of life of both the patient and caregiver are significantly improved. Apart from protocol-based categorization of the patients, individualized thorough clinical examinations are mandatory to identify these patients.
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Prevalence of suicidality and its correlates in geriatric depression: A multicentric study under the aegis of the Indian Association for Geriatric Mental Health p. 62
Sandeep Grover, Swapnajeet Sahoo, Ajit Avasthi, Bhavesh Lakdawala, Amitava Dan, Naresh Nebhinani, Alakananda Dutt, Sarvada C Tiwari, Abmajid Gania, Alka A Subramanyam, Jahnavi Kedare, Navratan Suthar
DOI:10.4103/jgmh.jgmh_35_19  
Aim of the Study: This study aimed to evaluate the prevalence and risk factors for suicidal ideations (SIs) and suicidal attempts (SAs) among elderly patients with depression, seeking treatment in psychiatric setups. Methodology: The study sample comprised 488 elderly patients (age ≥60 years) with depression recruited across eight centers. These patients were evaluated on the Columbia Suicide Severity Rating Scale, Geriatric Depression Scale-30, Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-15 Scale, UCLA Loneliness Scale, Revised Social Connectedness Scale, and Montreal Cognitive Assessment Scale. Results: “Wish to die” was present in one-fifth (21.7%) and about one-fourth (26.6%) of the study samples at the time of assessment and in the lifetime, respectively. Overall, one-fourth (25.8%; n = 126) of the participants had SIs at the time of assessment and two-fifths (41.5%; n = 203) had SIs in the lifetime. Overall, about one-tenth (9.2%) of the participants made an SA just before assessment and one-sixth (16.6%) had at least one SA in the lifetime. Compared to those with no SIs in the lifetime, those with current and lifetime SIs had lower age of onset and longer duration of illness, less often had a comorbid physical illness, more often had recurrent depressive disorder, had significantly higher anxiety as assessed on GAD-7 scale, and had significantly higher prevalence of loneliness and significantly higher prevalence of cognitive deficits. When those with any current and lifetime SAs and those with no lifetime SAs were compared, those with SAs had longer duration of current treatment and more often had comorbid physical illness and significantly higher cognitive deficits. Conclusions: The present study suggests that about one-fourth (25.8%) of the elderly with depression have SIs at the time of assessment and about two-fifths (41.5%) have lifetime SIs. About one-sixth of the elderly patients with depression make at least one SA in the lifetime and about one-tenth attempt suicide in recent past. In terms of risk factors for SIs and SAs, the present study suggests that the presence of comorbid anxiety, loneliness, and cognitive deficits possibly predispose the elderly to suicidal behaviors.
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Clinical profile of early-onset dementia from a geriatric clinic in South India p. 71
Shiva Shanker Reddy Mukku, Naga V. S S. Gorthi, Vijaykumar Harbishettar, Palanimuthu Thangaraju Sivakumar, Mathew Varghese
DOI:10.4103/jgmh.jgmh_16_19  
Background: Early-onset dementia (EOD) defined as dementia with clinical onset before the age of 65 years, has estimated proportion ranging up to 45.3%. Although EOD leads to severe psychosocial consequences that affect people in their latter part of working age, the literature from India is limited. Objective: The aim of this study is to investigate the profile of patients with EOD attending Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India. Materials and Methodology: All records of patients attending the Geriatric Clinic and Services, diagnosed with EOD between January 2017 and June 2018 with their details pertaining to sociodemographic, clinical, risk factors, and behavioral problems were examined. Results: Of the 320 patients with cognitive complaints seen during the period of 18 months, 108 (33.75%) patients had a diagnosis of EOD. The mean age at onset of illness was 55.38 (Standard deviation - 6.53) years (range - 34–65 years). Of these 58 (53.6%) patients found to have Alzheimer's dementia (AD), 31 (28.7%) have fronto-temporal dementia (FTD), 6 (5.5%) have vascular dementia (VaD), 3 (2.7%) patients have Parkinson's disease-related dementia, and 6 (5.5%) have unspecified dementia. Discussion: During the 18 months, the EOD patients constituted one-third of all dementia patients visiting Geriatric Clinic. Degenerative etiology was the main diagnostic cluster. The most common type was AD, similar to senile type of dementia, was followed by FTD and VaD. The study showed a delay of 3.18 years in seeking consultation. Conclusion: EODs seems to have higher degenerative etiology and with higher associated behavioral and psychological symptoms. There is a need for setting up specialized memory clinics.
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Diabetic complications and poor mental health in the aging population p. 78
Rishav Bansal, Sunny Singhal, Gevesh Dewangan, Pramod Kumar, Sujata Satpathy, Nand Kumar, Sada Nand Dwivedi, Aparajit Ballav Dey
DOI:10.4103/jgmh.jgmh_22_19  
Introduction: Diabetes is a known risk factor for mental health disorders in the older population. This effect can be due to direct impact of chronic disease or indirectly due to the impact of diabetic complications. This study aims to assess the association of individual diabetic complications with depression, generalized anxiety disorder (GAD), cognitive impairment, and quality of life (QOL) in older diabetic population. Materials and Methods: A cross-sectional study was performed in Geriatric Medicine OutPatient Department from November 2014 to June 2016. One hundred and eighty diabetic patients were diagnosed using the American Diabetes Association (ADA)-2015 diagnostic criteria and were included in the study. They were assessed for the presence of diabetic complications (diabetic retinopathy, diabetic nephropathy, diabetic neuropathy, coronary artery disease , and cerebrovascular disease (CVD) as per the ADA-2015 guidelines. They were also subjected to assessment for the presence of depression, GAD, cognitive impairment, and health-related QOL by using Geriatric Depression Scale, Mini-International Neuropsychiatric Interview, Montreal Cognitive Assessment , and WHOQOL-BREF scale, respectively. The Chi-square test/Fisher's exact test and unpaired t-test were used for the statistical analysis. Results: Diabetic neuropathy and CVD in diabetes have higher risk of depression (49.3% vs. 27%; P = 0.002) and cognitive impairment (82.4% vs. 50.9%; P = 0.013), respectively, as compared to those with diabetes without such complications. Patients with diabetic nephropathy have poor environmental domain QOL (68.02 ± 15.16 vs. 72.82 ± 14.86; P = 0.040) as compared to those without diabetic nephropathy. Conclusions: Diabetic complications in old age are independently associated with increased risk of mental health disorders and impaired health-related QOL. Thus, patients with diabetic complications should be specifically assessed and managed for mental health disorders in addition to the management of metabolic abnormalities.
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Psychometric properties of the Geriatric Depression Scale (Kannada version): A community-based study p. 84
Jahnavi Rajgopal, Thittamaranahalli Varadappa Sanjay, Megha Mahajan
DOI:10.4103/jgmh.jgmh_29_19  
Background: Mental disorders have got high prevalence and low priority in most of the countries worldwide, of which depression among elderly population being the most common treatable medical condition. In developing countries such as India, there is a scarcity of adequately trained mental health professionals. In this context, validated Kannada version of the the Geriatric Depression Scale (KGDS)-15 is considered an alternative to screen the depression among the elderly. Objectives: The objectives of this study are to assess the psychometric properties of KGDS-15 in an urban community. Materials and Methods: A cross-sectional study was conducted in the urban field practice area of medical college, Bengaluru for a period of 6 months after the Institutional Ethics Committee clearance. House-to-house survey was done to enumerate the total number of the elderly; of 347 elderly, 100 elderly were selected by probability proportion to population size technique and linguistically validated KGDS-15 was applied to screen for depression, and psychiatrist assessed the depression status by clinical evaluation using the Structure Clinical Interview for DSM-IV and dementia status using the Mini-Mental Status Examination. Results: The KGDS-15 had 100% sensitivity and 88.8% specificity. The area under curve values for KGDS-15 was 0.98 (P < 0.0001), and the optimum cutoff score was >7, with a sensitivity of 1.0 and specificity of 0.95. The Cronbach's alpha is 0.92 and test-retest reliability is 0.99. Conclusions: The KGDS-15 had good psychometric properties and a valid instrument for screening depression among the elderly in the urban community.
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Quality of life in elderly bipolar disorder patients p. 88
Disha D Parikh, Smita N Panse
DOI:10.4103/jgmh.jgmh_37_19  
Context: Bipolar disorder (BD) in elderly individuals is a prevalent and disabling condition. The disorder also has an impact on the quality of life (QoL). However, very few studies have systematically examined the magnitude of QoL impairments in bipolar patients, especially in the older age group. Aims: The objective was to study the QoL and its correlation with sociodemographic factors and clinical variables in elderly BD patients. Settings and Design: A cross-sectional study was done in the psychiatry department at a tertiary hospital. Subjects and Methods: We examined QoL scores of 100 elderly (age range: 60–82 years) patients with BD on regular maintenance treatment for 1 year. Psychopathology was assessed using the Young Mania Rating Scale and Hamilton Rating Scale for Depression (HAM-D). QoL was assessed using QoL scale (World Health Organization QOL [WHO-BREF). Statistical Analysis Used: Statistical Package for the Social Sciences was used, and analysis of variables was done using unpaired t-test and Pearson correlation coefficient. Results: Female patients had significantly lower scores on physical and psychological domains in the WHO quality of life-BREF scale (P < 0.01). The unmarried/divorced/widowed population had lower QoL scores in the physical and social relationships domains (P < 0.01). Patients with lower socioeconomic status had lower QoL scores on physical and environmental domains of QoL (P < 0.05). There was significant negative correlation between the QoL and the total number of episodes (P < 0.05; R2 = 0.09) and between the QoL and duration of illness (P < 0.05; R2 = 0.05). Higher HAM-D scores were associated with poor QoL (P < 0.05; R2 = 0.07). Conclusions: This study offers insight into patterns of QoL in BD in the elderly. The study concludes that the duration of illness and the total number of episodes have a significant negative impact on QoL. Furthermore, undercurrent depressive features can be overlooked, leading to decline in the QoL.
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Determinants of quality of life among the elderly population in urban areas of Mangalore, Karnataka p. 94
Shilpa Devraj, Mackwin Kenwood Dímello
DOI:10.4103/jgmh.jgmh_23_19  
Introduction: India is going through a phase of demographic transition progressing to population aging. Poor health-related quality of life (QOL) among the elderly is often associated with physical deterioration, psychological trauma, and mental weakness. The rise in the social and health requirements of older adults has to be addressed optimally and comprehensively. Materials and Methods: A cross-sectional study was carried out on elderly individuals of urban Mangalore to determine their QOL. The multistage sampling design was used to obtain 384 elderlies aged 60 years or older. Results: The average QOL was observed among 74.3% of the elderly (mean score: 80.28–91.1). The factors such as age of the individual, gender, marital status, living status, education, occupation, socioeconomic status, interaction with people, use of mobile phones, and social media determined the QOL of the elderly (P < 0.001). Conclusion: Inclusionary measures such as participation in social clubs should be encouraged at the community level to enhance the QOL among the elderly population. Measures to improve the awareness of government schemes should be considered.
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CASE REPORTS Top

Incubus syndrome in late-onset schizophrenia p. 99
Yogender Kumar Malik, Sandeep Grover
DOI:10.4103/jgmh.jgmh_21_19  
The term “incubus syndrome” is proposed to describe patients suffering from the delusion that they have been sexually approached at night by an unseen lover. This phenomenon has been rarely described in patients with schizophrenia. However, it is rarely been described in elderly patients with late-onset schizophrenia. In this report, we present a patient with late-onset schizophrenia, who had a phenomenon of incubus syndrome, in addition to other psychopathology.
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An interesting presentation of psychotic catatonia in an elderly patient with alcohol dependence p. 101
Migita Michael Dcruz, Jayant Mahadevan, Prabhat Kumar Chand, Pratima Murthy
DOI:10.4103/jgmh.jgmh_33_19  
Catatonia is a neuropsychiatric syndrome with multifactorial etiopathogenesis. It can be seen in patients with alcohol dependence in the context of withdrawal in the presence of comorbid psychiatric disorders (substance induced or independent) or as a consequence of medications used to treat dependence. This is a case of an elderly patient with alcohol dependence, and a prior episode of psychosis, who developed acute psychosis with catatonia following the concurrent use of disulfiram and baclofen.
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Hyposmia in geriatric depression can be a meningioma p. 104
Muruganandam Partheeban, Sundararajan Mathivanan
DOI:10.4103/jgmh.jgmh_25_19  
Depression in the elderly population can be a manifestation of underlying neurological and systemic disorder. It can be harbinger in many neurological illnesses such as Parkinson's disease and Alzheimer's dementia. It can present as early as 10 years before the onset of clinical neurological signs in dementia. Brain tumors can present with varying psychiatric symptoms such as depression, anxiety, cognitive or personality changes, or schizophrenia. Olfactory groove meningioma is uncommon benign brain tumor which accounts for <10% of all intracranial meningiomas. Olfactory meningioma, which occurs in the anterior cranial fossa, can compress the frontal lobe, thereby rarely present only as depressive symptoms in the absence of neurological symptoms. The present case report illustrates depression with hyposmia in elderly women, which unmasked the giant olfactory groove meningioma and significant improvement in depressive symptoms following surgical resection.
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Heart and brain: A new association – Report of a family with “probable frontotemporal dementia and heart block” p. 106
Sadanandavalli Retnaswami Chandra, Pooja Mailankody, Manisha Gupta
DOI:10.4103/jgmh.jgmh_31_19  
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