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   Table of Contents - Current issue
January-June 2018
Volume 5 | Issue 1
Page Nos. 1-80

Online since Wednesday, June 27, 2018

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Metabolic-cognitive syndrome: Is this understanding useful? p. 1
Sandeep Grover
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Dementia in Indian cinema: A narrative review p. 4
Badr Ratnakaran, Sethulakshmi Sreevalsam Anil, Nisha Suresh
Indian cinema is known for portraying social, cultural, political issues, and this also includes issues in mental health. The objective of this paper is to provide a narrative review of the portrayal of dementia in Indian cinema. The films were identified after discussion with various experts in person, telephone, e-mail correspondence and via social media. Fifteen films portraying balanced and unbalanced versions of dementia and its related issues have been identified. Caregiver issues have also been discussed in the films. However, treatment and other interventions have not been adequately portrayed. It can be concluded that these films can be used as a resource for movie clubs as a part of teaching curriculum during postgraduate and undergraduate training. They can be an excellent medium to understand cultural issues related to dementia in the community.
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Bringing dementia-care back into psychiatry p. 10
Ajit Avasthi
Dementia with over 46 million people suffering from it has become an illness which cannot be ignored. The confusion regarding whether dementia is a neurological or a psychiatric illness has been existing for a long. Conventionally, dementia has been viewed as a neurological illness with the organicity of the same being given utmost importance. However, we cannot ignore the vast contribution of psychiatry in the discovery of dementia. Furthermore, the new concept regarding psychiatric and neurological illnesses has challenged the fact that dementia is a completely neurological illness, especially considering the vast similarities between psychiatric disorders and dementia. This confusion regarding whether it is a neurological or a psychiatric illness has created difficulty in the management of these patients. The similarities between dementia and psychiatric disorders are visible at the level of localization of lesions, the symptoms, especially the behavioral and the psychotic symptoms, the methods of diagnosis, and the treatment strategies, especially the nonpharmacological ones, which are in fact more effective than the pharmacological strategies. The nonpharmacological aspects include not only behavioral strategies but also focus on breaking the bad news and addressing the caregiver burden and the legal aspects. All this puts a psychiatrist at an advantage in treating these patients, when compared to other specialists, given our expertise with history taking, mental status examination, pharmacological management of the behavioral issues, and especially nonpharmacological aspects.
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Geriatric mental health: The challenges for India p. 16
Pragya Lodha, Avinash De Sousa
Geriatric mental health has yet to receive its due recognition in India. Geriatric mental health is plagued by many challenges that prevent the development and progress of its services. The present article is a narrative review that looks at the various challenges faced by geriatric mental health in India. The article describes different specific and general unique challenges faced by geriatric mental health and discusses in detail the nature of each challenge and what must be done to overcome it. The challenges range from demography of Indian aging to sexual issues in the elderly, geriatric depression, dementia care, and the aging lesbian, gay, bisexual, and transgender community. Various issues related to policy and research that challenge geriatric mental health are also discussed. The need to incorporate geriatric mental health into primary health care along with the need to train primary care workers and preventive work aimed at suicide prevention in the elderly is stressed. The article addresses these challenges with the aim of positing before the clinician the various challenges faced by geriatric mental health in India in the current era.
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Disability and caregiver burden: Relation to elder abuse p. 30
Sreelakshmi Vaidyanathan, Enagandula Rupesh, Alka A Subramanyam, Surbhi Trivedi, Charles Pinto, Ravindra Kamath
Aims: The aim of this study is to assess the prevalence and severity of elder abuse, its relation to elder disability and caregiver burden and to ascertain the better predictor between them for abuse. Materials and Methods: A total of 100 patients ≥60 years with their caregivers (50 from medical geriatric outpatient department [OPD] and 50 from psychogeriatric OPD) were recruited from a tertiary care center after screening for cognitive issues significant enough to hamper the responses using Elderly Cognition Assessment Questionnaire (score <5 excluded). Semi-structured pro forma and scales were applied (Elder abuse screening instrument for abuse, World Health Organization Disability Assessment Schedule 2.0 to assess functioning and disability, and Zarit's Burden Interview for caregiver burden). Results: Mean scores of abuse, disability, and degree of burden were 3.58, 24.21, and 14.87, respectively. Significantly greater abuse was found in disability domains of cognition and getting along with people in the psychiatric population than the medical population of the study. Furthermore, significant correlation was found individually of disability and degree of burden with the abuse score (P = 0.005 and 0.000, respectively), and degree of burden (r2 = 26) is a better predictor of abuse in comparison to disability (r2 = 8). Conclusion: Elder abuse appears to be directly correlated with disability (psychological > physical) and caregiver burden. To reduce abuse, we need targeted therapy aimed at easing caregiver burden in addition to measures to reduce and aid for elder disability.
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Indian Association for Geriatric Mental Health's multicentric study on depression in elderly: Symptom profile and influence of gender, age of onset, age at presentation, and number of episodes on symptom profile p. 35
Sandeep Grover, Ajit Avasthi, Swapnajeet Sahoo, Bhavesh Lakdawala, Naresh Nebhinani, Amitava Dan, Alakananda Dutt, Sarvada C Tiwari, Ab. Majid Gania, Alka A Subramanyam, Jahnavi Kedare
Aim of the Study: To assess the symptom profile of depression among elderly patients presenting to psychiatric outpatient settings. An additional aim was to evaluate the influence of gender, age of onset, age at presentation, and type of episode (i.e., the first episode versus recurrent depressive episodes) on symptom profile of geriatric depression. Materials and Methods: This multicentric study was conducted at eight centers in which 488 elderly patients (aged ≥60 years) with depression were evaluated on Geriatric Depression Scale (GDS-30), Generalized Anxiety Disorder-7 Scale (GAD-7), Patient Health Questionnaire-15 (PHQ-15) scale, and Columbia Suicide Severity Rating Scale. Results: Males had significantly higher prevalence of comorbid substance dependence, whereas females had significantly higher prevalence of comorbid psychiatric disorders. As per the GDS-30, about two-third or more of the study sample had symptoms of feeling helpless (71.7%), often getting restless and fidgety (70.1%), dropped many of their activities (68.4%), frequently feel like crying (67.4%), trouble concentrating (67%), feels pretty worthless (66.4%), often feeling downhearted and blue (65.8%), frequently getting upset over little things (64.8%), and not satisfied with life (62.9%). More than two-third of the sample had all the symptoms of anxiety as per the GAD-7 and 7 out of the 14 somatic symptoms as per the PHQ-15. When comparisons were made between males and females, significant difference in prevalence was noted for some of the depressive symptoms as assessed by the GDS-30 and somatic symptoms as assessed by the PHQ-15, but no differences emerged in terms of anxiety symptoms. Significantly higher proportion of females reported active suicidal ideation with specific plan and intent and had higher intensity of suicidal ideations. Differences in symptom profile were also noted with regard to age of onset (<60 and ≥60 years), age at presentation (<70 and ≥70 years), and type of depression (single versus multiple episodes). Conclusion: The present study suggests that somatic and anxiety symptoms are highly prevalent among elderly patients with depression. Further, it is evident that there are certain differences in the symptom profile of depression among male and female patients with depression. The present study also reveals that age of onset, age at presentation, and number of episodes could also influence the symptom profile of depression among the elderly.
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Psychiatric morbidity among elderly presenting to emergency medical department: A study from tertiary hospital in North India p. 49
Sandeep Grover, V Natarajan, Seema Rani, Sai Chaitanya Reddy, Ashish Bhalla, Ajit Avasthi
Background: Geriatric population is on a steady rise since the past decade especially in densely populated countries like India. Elderly form a significant proportion of patients presenting to the medical emergency department and they warrant more attention in terms of mental health conditions as they are more predisposed to conditions such as delirium and cognitive impairment. Aim of this Study: This study aimed to evaluate the prevalence of psychiatric morbidity including substance use disorders among elderly (age ≥60 years) presenting to emergency medical outpatient services. Methodology: A total of 300 patients aged 60 years and above attending the medical emergency department of tertiary care hospital were approached, out of which, 232 participated. All the patients were assessed by Confusion Assessment Method, Modified Mini Screen and Alcohol, Smoking, and Substance Involvement Screening Test. Those found positive on any of the screening instrument were further evaluated on International Classification of Diseases-10 criteria, by a semi-structured interview to confirm the psychiatric diagnosis. Results: At least, one psychiatric diagnosis, i.e., either axis-I psychiatric disorder or substance dependence disorder was seen in 62% of cases. Nearly, half of the patients (47.4%) fulfilled at least one axis-I psychiatric diagnosis other than the substance dependence disorder at the time of assessment, with delirium being the most common, seen in about one-third (34.1%) of the participants. Other psychiatric diagnoses in the study sample included dementia (9.5%), depressive disorders (8.2%), adjustment disorder (3%), and anxiety (not otherwise specified) disorder in 3.4% of participants. About one-third (31%) of the participants had tobacco dependence, currently, using and one-fifth (19.8%) of patients had alcohol dependence syndrome currently using. Higher prevalence of delirium and dementia was noted among patients who were aged ≥70 years. Conclusion: The present study shows that elderly patients presenting to medical emergency department have a high prevalence of psychiatry morbidity. Accordingly, there is a need to reorganize psychiatric services and training to improve the identification and management of mental disorders among elderly patients presenting to emergency.
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Methylprednisolone abuse: Report of two cases and review of literature p. 55
Aseem Mehra, Sandeep Grover
Steroids are known to have mood-elevating effects and are commonly used by quacks for various medical ailments. In this report, we present two cases, who were started on corticosteroids for somatic symptoms, who continued to abuse the steroids and became dependent on the same because of the mood-elevating effect and feeling of general well-being with these medications.
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Impact of cognitive activity combined with physiotherapy in a bedridden elderly: A case study p. 58
Hariharasudhan Ravichandran, Balamurugan Janakiraman, Subramanian Sundaram, Berihu Fisseha, Asmare Yitayeh Gelaw
Rehabilitating hospitalized bedridden elderly patients is a challenging task for multidisciplinary team. The reasons for their hospital stay, their level of physical activity before hospitalization, and their disease prognosis interfere with the physiotherapist's intervention in mobilizing the patient out of bed. In this case study, Mr. S, a 66-year-old patient, hospitalized for hyponatremia and bounded to bed for 2 weeks due to his comorbid illness (hypertension and type II diabetes) and delirium was mobilized with cognitive activity, and the physiotherapy interventions have been discussed. This case study demonstrates the impact of cognitive therapy combined with physiotherapy interventions in mobilizing the elderly patient with delirium. In this case study, the patient was treated with cognitive therapy and physiotherapy for 7 days. Baseline and postintervention assessment of timed up and go test (TUG) and 6-min walk test (6MWT) was screened by a senior physiotherapist who is not aware of the interventions provided. Cognitive therapy and physiotherapy interventions are provided by a therapist who is not aware of the baseline and postintervention results. After 7 days, Mr. S was physically active and performed TUG in 12 s and achieved 245.4 m in 6MWT. Cognitive activity is essential among elderly patients expressing the state of delirium. Without sound cognition, it is not easy to rehabilitate elderly patients. In this case study, cognitive activity combined with physiotherapy is found to be effective.
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Prescribing cascade in a geropsychiatric patient: A slippery slope p. 62
Patricia A Pepa, Michael H Langley-DeGroot, Oresta S Rule
A prescribing cascade is a situation, in which an adverse drug reaction is mistaken for a new medication condition, and a new medication is prescribed. We present a case, in which risperidone led to a prescribing cascade in a geriatric patient. We share this case to improve awareness and vigilance of prescribing cascades in the geropsychiatric population.
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Role of Vitamin D in schizophrenia in elderly patient Highly accessed article p. 65
Javed Ather Siddiqui, Shazia Farheen Qureshi, Yousef Bin Ahmed Shawosh
Vitamin D deficiency is common in the patient with mental illness such as schizophrenia; several environmental risk factors for schizophrenia, such as season of birth, latitude, and migration, have been linked to Vitamin D deficiency. Recent studies have suggested a potential role of Vitamin D in the development of schizophrenia, for example, neonatal Vitamin D status is associated with the risk of developing schizophrenia in later life. Here, we report a case of Vitamin D deficiency presenting with schizophrenia. Vitamin D supplementation is promising treatment strategy to prevent relapse to improve psychotic symptoms, and physical health in patients with schizophrenia should be further explored in future studies.
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The missing link between late-onset separation anxiety and dementia p. 68
Lokesh Kumar Singh, Spoorthy Sai Mamidipalli, Narendra K Bodhey, Neethu K Nandan, Nobal Chandrakar
Relation of behavioral and psychological symptoms with dementia has several implications. They predict treatment and prognosis in patients. Anxiety and its association as a psychological symptom despite being well known is not addressed properly in clinical settings. Although generalized anxiety disorder is most commonly seen in patients with dementia, some of them might also present with late-onset separation anxiety. Presentation of separation anxiety in the index patient signifies the fact that atypical age of onset, acuteness of presentation points toward an underlying organic etiology. Patients with such clinical features should be thoroughly assessed for dementia. Clinicians should be aware of the association between separation anxiety and organic deficits.
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Red herrings in the diagnosis of frontotemporal dementia: A case of probable bipolar disorder evolving into frontotemporal dementia p. 71
Shiva Shanker Reddy Mukku, Manjula Simiyon, Umamaheswari Vanamoorthy, Santosh Loganathan, Mathew Varghese
Bipolar illness and Frontotemporal dementia (FTD) share many common features. The clinical features of mania such as excessive cheerfulness, hyper-sexuality and overspending can mimic impaired judgement and loss of inhibition seen in FTD. The depressive features such as anhedonia, decreased social interaction can mimic apathy associated with FTD. Among the FTD subtypes the behavioural variant of FTD (bv-FTD) can mimic a bipolar disorder, especially when it occurs in late life. Initially, patients with behavioural variant of FTD generally have behavioural changes with relatively preserved memory thus presenting a diagnostic challenge. The literature on bipolar disorder converting or progressing to FTD is limited to case reports and case series. In this case report we describe about an elderly gentleman with prior bipolar illness who later evolved into FTD. The diagnostic as well as management challenges have been discussed.
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Quetiapine-induced hyponatremia in elderly p. 75
Shiva Shanker Reddy Mukku, Palanimuthu Thangaraju Sivakumar, Shyam Sundar Arumugahm
Quetiapine is a second-generation antipsychotic used for the treatment of severe mental illness. Quetiapine has a relatively safer side effect profile with lesser propensity to cause extrapyramidal side effects. Antipsychotics have been rarely reported to cause hyponatremia, especially in the elderly. There is a paucity of literature on the association between quetiapine and hyponatremia. Elderly due to their multiple medical comorbidities and frequent polypharmacy are at higher risk of developing hyponatremia. In this article, we describe a case of elderly gentleman who presented with chronic hyponatremia probably secondary to quetiapine use.
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Expanding the range of interventions to prevent and effectively respond to the social problem of elder abuse p. 78
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava, Jegadeesh Ramasamy
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Quantification of dementia: Are we there yet? p. 79
Avinash De Sousa
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