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   Table of Contents - Current issue
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July-December 2018
Volume 5 | Issue 2
Page Nos. 81-174

Online since Thursday, December 27, 2018

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GUEST EDITORIAL  

Mobile phone use in the elderly: Boon or bane? p. 81
Alka A Subramanyam, Shipra Singh, Nitin B Raut
DOI:10.4103/jgmh.jgmh_32_18  
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REVIEW ARTICLES Top

Insomnia in elderly: A neglected epidemic p. 84
Shiva Shanker Reddy Mukku, Vijaykumar Harbishettar, Palanimuthu T Sivakumar
DOI:10.4103/jgmh.jgmh_15_18  
Sleep is an important vital function. Sleep promotes many functions such as restoration of body, repair of tissues, immune regulation, and consolidation of memory. Insomnia is one of the most common complaints in patients with mental health problems. The prevalence of insomnia is higher in elderly than in general population. The reasons could be due to physiological changes in sleep architecture with aging, high medical morbidity, multiple medication, loneliness, and environmental factors causing sleep disturbances. Although insomnia is a common troubling problem in the elderly, only minority seek professional help. Some elderly self-medicate with over-the-counter medications for their sleep problems. These practices lead to serious adverse effects over the long term. There are many myths related to insomnia in elderly. Thus, insomnia in elderly is often under-recognized and under-treated problem. In this article, we review the literature on sleep problems in the elderly and discuss the systematic evaluation of insomnia in the elderly.
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The role of epigenetics in Alzheimer's disease p. 94
Purushothaman Sujeetha, Jeenu Cheerian, Preethi Basavaraju, Puthamohan Vinayaga Moorthi, Arumugam Vijaya Anand
DOI:10.4103/jgmh.jgmh_33_17  
Neurodegenerative diseases are debilitating and incurable condition resulting in the progressive degeneration of nerve cells which causes problems with movement or mental functioning. Alzheimer's disease is the most common form of dementia and an irreversible neurodegenerative disorder. The mechanism of Alzheimer's disease is still unknown. The changes in the primary DNA sequence due to heritable alterations in the gene are known as epigenetics. The most studied epigenetic mechanisms are DNA methylation, histone modifications, and noncoding RNAs. Therefore, this change triggers the alterations in the transcriptional level of genes which are involved in the pathogenesis of Alzheimer's disease. Over the past decade, it is progressively clear that the epigenetic mechanisms play an important role in the pathogenesis of Alzheimer's disease. The literature search was performed on reviews addressing the topics in the databases PubMed and Google Scholar. This review focuses on the three major epigenetic mechanisms and their role in the pathogenesis of Alzheimer's disease.
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ORIGINAL ARTICLES Top

Relationship of loneliness and social connectedness with depression in elderly: A multicentric study under the aegis of Indian Association for Geriatric Mental Health p. 99
Sandeep Grover, Ajit Avasthi, Swapnajeet Sahoo, Bhavesh Lakdawala, Amitava Dan, Naresh Nebhinani, Alakananda Dutt, Sarvada C Tiwari, Ab Majid Gania, Alka A Subramanyam, Jahnavi Kedare, Navratan Suthar
DOI:10.4103/jgmh.jgmh_26_18  
Aim of the Study: This study aimed to evaluate the prevalence of loneliness and its relationship with social connectedness and depression in elderly. Additional aims were to evaluate the demographic and clinical factors associated with loneliness and social connectedness in elderly patients with depression. Methodology: The study sample comprised 488 elderly patients (age ≥60 years) with depression recruited across 8 centers. These patients were evaluated on Geriatric Depression Scale (GDS-30), Generalized Anxiety Disorder-7 Scale (GAD-7), Patient Health Questionnaire-15 (PHQ-15) Scale, Columbia Suicide Severity Rating Scale, UCLA Loneliness Scale (LS), and Revised Social Connectedness Scale. Results: About three-fourth (77.3%) of the entire sample reported the presence of loneliness. With respect to specific loneliness symptom, 62.5% reported lack of companionship, 58.7% reported being left out in life, and 56.5% of the individuals reported felt isolated from others. No gender differences were noted in the prevalence of any loneliness symptom. Higher loneliness scores had significant positive correlation with severity of depression, anxiety, and somatic symptoms as assessed by GDS-30, PHQ-15, and GAD-7, respectively, in individuals of both the genders. Higher social connectedness was associated with higher level of anxiety and lower loneliness in females only. Being currently single, older age, longer duration of illness, presence of family history of mental illness, presence of comorbid physical illness, and absence of substance abuse were associated with higher loneliness. With regard to suicidality, higher loneliness was associated with nonspecific active suicidal thoughts, active suicidal ideations with and without intent, nonsuicidal behavior, and higher intensity of suicidal ideations. Conclusions: About three-fourth of the elderly patients with depression also have associated loneliness. Loneliness is associated with higher severity of depression, anxiety, and somatic symptoms. Severity of depression is associated with loneliness but not with social connectedness. Lower social connectedness among elderly females with depression is associated with higher loneliness, but this is not true for elderly males with depression.
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Prevalence of physical comorbidity and prescription patterns in elderly patients with depression: A multicentric study under the aegis of IAGMH p. 107
Sandeep Grover, Ajit Avasthi, Swapnajeet Sahoo, Bhavesh Lakdawala, Amitava Dan, Naresh Nebhinani, Alakananda Dutt, Sarvada C Tiwari, Ab Majid Gania, Alka A Subramanyam, Jahnavi Kedare
DOI:10.4103/jgmh.jgmh_27_18  
Aim of the Study: This study aims to evaluate the prevalence of physical comorbidities and prescription patterns in elderly patients with depression. Materials and Methods: This study included 488 elderly patients (aged ≥60 years) with depression recruited across eight centers. A self-designed physical comorbidity checklist was used to assess for the presence of various physical comorbidities and prescription of psychotropic medications was recorded. Results: More than three-fourth of the study sample (n = 384; 78.7%) had at least one physical comorbidities and one-third (36.7%) of the samples had at least three physical illnesses. About half of the study samples had hypertension (47.3%) and slightly more than one-fourth had diabetes mellitus (29%). The most common physical illness involved the cardiovascular system (51.5%), followed by endocrinological system (39.3%), orthopedic and joint-related diseases (35%), and ophthalmological problems (22.3%). Those with physical comorbidity had higher severity of depression, anxiety, and somatic symptom. Sertraline was the most preferred antidepressant followed by escitalopram and mirtazapine. Only 12.7% of the sample was prescribed antipsychotics of which quetiapine and olanzapine were the most commonly used agents. Benzodiazepines were prescribed to more than half of the study samples (56.55%), with clonazepam being the most preferred benzodiazepine followed by lorazepam. Compared to those without hypertension, those with hypertension were more commonly prescribed sertraline and escitalopram and less commonly prescribed fluoxetine. Similarly, compared to those without diabetes mellitus, those with diabetes mellitus were more commonly prescribed sertraline and less commonly prescribed fluoxetine. Conclusion: Comorbid physical illnesses are highly prevalent in elderly participants with depression with hypertension being the most common physical comorbidity followed by diabetes mellitus and osteoarthritis. The presence of physical comorbidity is associated with more frequent prescription of sertraline and escitalopram.
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Antidepressant-associated hyponatremia among the elderly: A retrospective study p. 115
Sandeep Grover, Anish Shouan, Aseem Mehra, Subho Chakrabarti, Ajit Avasthi
DOI:10.4103/jgmh.jgmh_28_18  
Background: The use of antidepressants among elderly is associated with dreaded side effect of hyponatremia. However, there is limited information about specific risk factors associated with developing hyponatremia in elderly. Aim of the Study: The aim of this study was to evaluate the clinical risk factors for the development of hyponatremia among elderly patients started on antidepressant medications. Methodology: Using retrospective study design, patients who developed hyponatremia (n = 35) and those who did not develop hyponatremia (n = 43) with use of antidepressants, were matched on sociodemographic parameters and were compared for various parameters such as physical illness, other medications, and dose and type of antidepressant drug. Results: Higher proportion of those who developed hyponatremia had history of comorbid hypertension, were receiving antihypertensive agents, and were receiving 2 antihypoglycemic agents concomitantly. Majority of the patients who developed hyponatremia were receiving mirtazapine, followed by sertraline and venlafaxine. There was no association of hyponatremia with concomitant use of psychotropics, presence of other physical illnesses, comorbid dementia, and comorbid substance use. Conclusion: Antidepressant-associated hyponatremia is more commonly seen in patients with comorbid hypertension, those receiving any antihypertensive agent and those on more than one hypoglycemic agent.
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Dropout rates and reasons for dropout from treatment among elderly patients with depression p. 121
Sandeep Grover, Aseem Mehra, Subho Chakrabarti, Ajit Avasthi
DOI:10.4103/jgmh.jgmh_29_17  
Background: Adherence to medical treatment is a major challenge. A significant proportion of patient's dropout of treatment after the initial visit. Little is known about the reasons for such high dropouts. Aim: This study aimed to evaluate the dropout rates and reasons for dropout from treatment among elderly patients with depression attending a tertiary care psychiatry outpatient facility. Methodology: One hundred and forty consecutive new patients aged 60 years or more, attending the psychiatry walk-in clinic, diagnosed with depressive disorders were assessed at baseline and then contacted at 6 months and 1 year to evaluate the follow-up status and reasons for dropout of treatment. Results: Out of the 140 participants, 132 could be contacted after initial registration with the clinic. About two-fifths (n = 58; 41.4%) never return back to the clinic after the first visit. By 6 months and 1 year, 105 (75%) and 126 (90%) patients had dropped out of treatment. When the reason for dropout of those who dropped out “very early (i.e., never returned back)” were evaluated, the most common reason for dropout was “no relief” of symptoms, and this was closely followed by complete relief of symptoms. Among those who followed up at least once, but had dropped out at 6 months, the most common reason for dropout was complete relief of symptoms, and this was closely followed by “no relief” and “worsening of illness” being the other common reasons of dropout. Among those who dropped out after 6 months, the most common reason for dropout was complete relief of symptoms. None of the demographic variable emerged as a predictor of dropout at any time point. Few clinical variables were associated with dropout of treatment. Conclusion: Very high proportion of elderly patients with depression dropout of treatment prematurely. Providing proper information to the patients at each visit can help in reducing the treatment dropout rates.
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Elder abuse and its association with depression and social support: A community-based study from Tezpur, Assam p. 128
Ananya Bordoloi, Arif Ali, Sabana Nasrin Islam
DOI:10.4103/jgmh.jgmh_13_18  
Background: Abuse among older adults is a sensitive issue that needs an elaborative research study in the Indian context, specifically in rural areas. A drastic change in the sociocultural aspects of looking at this vulnerable group of people is not only limited to urban areas but also touches the simple rural life. Thus, the present study aimed to know about the prevalence of abuse and its associations with depression and social support among the rural older adults. Materials and Methods: A cross-sectional rural community-based study was conducted. The universe of the study comprised older adults residing under Mazgaon Panchayat, Tezpur, Sonitpur district of Assam. Two polling stations were randomly selected, using simple random sampling (lottery method) for the present study. Based on the two electorate lists, 141 older adults aged 60 years and above were listed out. From that list, 102 participants fulfilled the inclusion criteria and completed the interview. A semi-structured sociodemographic data sheet, Mini–Mental Status Examination, Vulnerability to Abuse Screening Scale, Geriatric Depression Scale (GDS), and the Multidimensional Scale of Perceived Social Support were administered to the respondents. Results: The prevalence of vulnerability was 28.4%, dependence was 13.7%, dejection was 45%, and coercion was 2% among the rural older adults. In the GDS, 29.4% of the respondents reported mild depression and 7.8% of respondents reported severe depression. In perceived social support, result shows that the mean score is high in the domain of family (24.62 ± 4.6) followed by significant others (24.52 ± 4.2) and friends (20.94 ± 6.05). Significant positive correlation was found between abuse and depression (r = 0.619, P = 0.01) among the older adults. Vulnerability to abuse has a significant negative correlation with perceived social support (r = −0.443, P = 0.01). Perceived social support and depression contributed significantly to the prediction of vulnerability to abuse among older adults (F(5,96) =18.684, P = 0.000) accounting for 4.93% variance. Conclusions: The older adults in the rural community are prone to vulnerability with a high risk of dejection. Depression strongly contributed to the variance on the overall vulnerability to abuse among older adults. The results of this study may guide in planning and implementing programs regarding prevention and management of abuse among older adults.
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Evaluation of emotional abuse perceived by the elderly living in nursing homes p. 134
Saliha Bozdogan Yesilot, Ayse Inel Manav, Ebru Gozuyesil
DOI:10.4103/jgmh.jgmh_8_18  
Introduction: In recent years, a significant increase in elderly population, modernization, industrial improvements, and greater involvement of women in the workforce have led to an increase in elder abuse. Elder abuse and frequent emotional abuse of the elderly have significant negative effects on their health and well-being. This study was conducted to evaluate the level of emotional abuse perceived by the elderly living in nursing homes. Materials and Methods: This cross-sectional and descriptive study was carried out between June 15 and July 15, 2017, at the Nursing Home Elderly Care and Rehabilitation Center in Adana, Turkey. The study sample consisted of a total of 118 elderly individuals who were selected using a simple random sampling method. Research data were collected using a personal information form and the perceived emotional abuse scale for adults (PEASA). The study results were evaluated using the IBM SPSS Statistics 22 (IBM SPSS, Turkey) program. The statistical significance level was set at P <0.05 for all analyses. Results: The mean age of the participants was 74.63 ± 6.76 years; of these, 50.2% were male, 70.3% were married, 29.7% were primary school graduates, and 83.1% had children. Their mean PEASA score was determined as 133.86 ± 35.23. The mean PEASA score of the elderly individuals without children was found to be statistically significantly higher than that of the elderly individuals with children (P = 0.044; P < 0.05). No statistically significant difference was found between the mean PEASA scores in terms of other descriptive characteristics of the participants (P > 0.05). Conclusion: The study results showed that the mean PEASA score of elderly individuals living in nursing homes was slightly above the scale mean score in general, and these individual perceived moderate emotional abuse.
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Inpatient treatment outcomes of aged substance-using patients admitted to a tertiary care center p. 139
Preethy Kathiresan, Siddharth Sarkar, Yatan Pal Singh Balhara
DOI:10.4103/jgmh.jgmh_9_18  
Background and Aims: Studies on aged substance users are few from the Indian subcontinent, though they are likely to represent a subgroup of patients with distinct clinical needs. This study aimed to present the inpatient treatment outcomes of such aged substance-using patients admitted to a tertiary care treatment facility in India. Methodology: This descriptive, retrospective chart-based study presents data of aged patients (age 50 years and above) admitted between January and December 2014 at the National Drug Dependence Treatment Centre, Ghaziabad. Results: A total of 72 aged patients were admitted during this period out of total 953 admissions (7.6% of the sample). All of them were male. Forty patients (55.6%) had a diagnosis of alcohol dependence and 32 (44.4%) had a diagnosis of opioid dependence. The mean duration of stay was 12.9 (±9.6) days. Of these 72 patients, treatment could be completed for 57 patients (79.2%), while seven patients left against medical advice, four were discharged on disciplinary grounds, three were shifted to another facility (two due to medical reasons), and one absconded. Treatment completion rate was least among aged patients with only opioid dependence (25.65%). Conclusion: Medical issues may be a consideration of premature discharge among aged patients admitted for the treatment of substance use disorders. Furthermore, treatment noncompletion is more among aged patients with opioid use disorder than among alcohol use disorder. Further studies are needed with prospective methodology for the assessment of various factors associated with treatment completion, which can help to address the treatment needs of aged patients with substance use disorders, which in turn can lead to better treatment outcomes for them.
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A qualitative study on the mental health needs of elderly in Kerala, South India p. 143
Pankajakshan Vijayanthi Indu, Sivaraman Remadevi, Sairu Philip, Thomas Mathew
DOI:10.4103/jgmh.jgmh_12_18  
Background: The proportion of elderly population in India is increasing and is the highest in Kerala. In an effort to review and modify the existing Old Age Policy, the state government deliberated on the need for elderly centered research. Aims: The aims of this study were to identify the unmet mental health (MH) needs of elderly population with attention to special groups such as widows and tribal population and to understand the gaps in delivery of MH services. Materials and Methods: A cross-sectional, qualitative study was undertaken in five districts of Kerala, selected purposively, ensuring representativeness, using 166 in-depth interviews and nine focus group discussions with elderly people from community and institutions and various key stakeholders. The interviews were transcribed and translated to English. Free listing of responses, domain identification, coding, summarization, and cross-tabulation were done. Semi-quantitative approach was used in analysis and presentation of report. Results: Depression, anxiety, insomnia, somatization, and dementia were the commonly reported MH problems in elderly people, especially institutionalized ones. Loneliness, isolation, neglect, and elder abuse were the major psychosocial issues identified. Poor social activities and interactions and poor utilization of MH services were also observed. Caregiver burden was found to be high and the available family support services were reported to be inadequate. Conclusions: MH problems were common in elderly, but utilization of MH services was low. This study highlights the need to improve accessibility, availability, and quality of MH services and family-support services for elderly.
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Diabetes: A risk factor for poor mental health in aging population p. 152
Rishav Bansal, Prasun Chatterjee, Avinash Chakrawarty, Sujata Satpathy, Nand Kumar, Sada Nand Dwivedi, Aparajit Ballav Dey
DOI:10.4103/jgmh.jgmh_5_18  
Background: Data on diabetes as a risk factor for mental health disorders in older population is limited. The health systems need to assess the burden on mental health disorders secondary to chronic diseases for better care provision. This study aims to assess the burden of depression, generalized anxiety disorder (GAD), and cognitive impairment among older patients with diabetes compared to age- and sex-matched nondiabetes and study the impact of diabetes on quality of life (QOL). Subjects and Methods: Cross-sectional comparative study was performed in Geriatric Medicine Outpatient Department (OPD) from November 2014 to June 2016. Ambulatory patients from OPD who provided informed consent were the participants of the study. They included 180 diabetic cases and 180 age- and sex-matched nondiabetic controls. The cases and controls were subjected to assessment for the presence of depression, GAD, and cognitive impairment using Geriatric Depression Scale, Mini International Neuropsychiatric Interview, and Montreal Cognitive Assessment, respectively. Health-related QOL was assessed with WHOQOL-BREF scale. They were also subjected to routine comprehensive geriatric assessment. McNemar's Chi-square test and Paired t-test was used for statistical analysis. Results: Older diabetics have significantly higher frequency of depression (35.6% vs. 16.7%), GAD (12.8% vs. 4.4%), and cognitive impairment (53.9% vs. 27.2%) compared to nondiabetics. In addition, they also report poorer health-related QOL. Conclusions: Diabetes in old age is associated with increased risk of mental health disorders and an accompanying poor health-related QOL in all domains. Thus, patients with diabetes require access to mental health support in addition to management of metabolic abnormalities. Future research to assess the impact of screening of mental health disorders on outcomes such as glycemic control, morbidity, and mortality is required.
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CASE REPORTS Top

Don't forget me: Pseudodementia associated with depression p. 159
Devakshi Dua, Sandeep Grover
DOI:10.4103/jgmh.jgmh_29_18  
Pseudodementia is understood as a clinical state, which occurs in the background of psychiatric disorders and mimics dementia. These patients are often diagnosed and treated as dementia, while the underlying disorder remains unrecognized and untreated. In this report, we discuss a patient suffering from depressive pseudodementia, who was previously treated as suffering from dementia. Management of depression with venlafaxine and electroconvulsive therapy was associated with significant improvement in functioning and behavior.
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First-episode psychosis in a 101-year-old male p. 162
Sayantani Mukherjee
DOI:10.4103/jgmh.jgmh_4_18  
An elderly gentleman, age 101 years, was brought in with first episode of onset of psychotic features, diagnosed with paranoid schizophrenia [ICD F20.0] as well as VLOSLP (Very Late Onset Schizophrenia Like Psychosis). He responded well to treatment and achieved complete remission. Remarkable in his case was his advanced age coupled with the lack of any the usual cognitive detriment prevalent in geriatric population. Notably, he had mildly elevated CRP (C- Reactive Protein) levels, which could both lend validity to neurodegenarative theory of schizophrenia and possibly indicate imminent onset of cognitive decline, but more longitudinal data is needed to be conclusive. Furthermore, despite satisfying the primary criterion of VLOSLP i.e. age of onset, his presentation and recovery does not fit its typical narrative, perhaps calling for more diversification in characterization of old age psychosis.
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A case report of preferential effectiveness of clonazepam over lorazepam in the management of a case of alprazolam withdrawal p. 165
Vrinda Saxena, Robin Victor, Arghya Pal
DOI:10.4103/jgmh.jgmh_25_18  
Benzodiazepines (BZDs) remain the mainstay in the management of withdrawal arising out of BZD use disorders. The choice of detoxifying agent is determined by the duration of action and also by the metabolic properties of the drug. Very rarely, we consider the chemical properties of the drug that we choose, though occasionally that may have profound clinical impact on the outcome. In this case report, we present the case of alprazolam withdrawal that was ineffectively managed by lorazepam and finally salvaged by the use of clonazepam. The chemical properties of the molecules involved and their clinical importance in the decision-making process have been subsequently reviewed.
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An old man who spit pearls-A case discussion p. 167
Supriya Agarwal, Apoorv Yadav, Arti Tyagi, Arpit Koolwal, Sandeep Choudhary
DOI:10.4103/jgmh.jgmh_19_18  
In the history of psychiatry, the contents of delusions have always interested the community of mental health professionals. We came across a 65-year-old patient with a peculiar delusion of spitting pearls. This study purports to discuss, first, the late age of onset of the delusions in the absence of any cognitive deficits along with unique delusional content and, second, the possible role of environment in the formulation of delusional content.
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A rare treatable cause for atypical frontotemporal dementia with multiple fractures in a young female p. 170
Sadanandavalli Retnaswami Chandra, Neeraja Koti, Ganaraja Valakunja Harikrishna, Pooja Mailankody, C Nitin Ramanujam, S Mathuranath Pavagada, Thomas Gregor Issac
DOI:10.4103/jgmh.jgmh_22_18  
Frontal and temporal lobe involvement in young people is seen in infections like neurosyphilis, Vitamin B12 deficiency, NPH, tumors and neurometabolic disorders apart from neurodegenerative dementias. Involvement of other parts of neuraxis in addition to Fronto temporal features is a clue for the specific diagnosis. Cerebro tendinous xantamatosis (CTX) is a rare treatable inborn error of bile acid metabolism. Reported average delay from onset of symptoms to diagnosis is about 16 years as per reports. A patient responds very well to treatment, if diagnosed before significant neurological damage had occurred. 40 year old female had been symptomatic for 11 years with tendon xanthomas, severe osteopenia and multiple fractures. She presented to us with features of Frontal, temporal and cerebellar involvement. Frontal and temporal lobe dysfunction in neuropsychological tests with MRI showing frontal, temporal and cerebellar atrophy. Genetic testing with whole exome sequencing showed TREM2 (-) (ENST00000373113) Exon 2 c.377T>G (p.Val126Gly) Homozygous Autosomal recessive. Short stature, tendon xanthomas, cognitive behavioral impairment with severe osteopenia is consistent with the diagnosis of CTX. CTX is a relatively rare and treatable cause for atypical Fronto temporal dementia.
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IAGMH AWARDS Top

Prof. (Dr.) Shiv Gautam Oration Award in Geriatric Mental Health p. 173

DOI:10.4103/2348-9995.248634  
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