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   Table of Contents - Current issue
July-December 2021
Volume 8 | Issue 2
Page Nos. 61-137

Online since Monday, January 31, 2022

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Should I prescribe or deprescribe! p. 61
Sandeep Grover
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Loneliness in older people: Spiritual practices as an alternative pathway to action, a treatise from India p. 63
Debanjan Banerjee
Loneliness is an abstract construct defined in multiple ways. It is a feeling of disconnectedness, emotional isolation, and subjective feeling of lacking social relationships. Research shows loneliness to be common in older people, which, in turn, is a potent risk factor for various physical and psychosocial health conditions. Chronic loneliness is a predisposing factor for suicide, worsens cognitive outcomes, and impairs quality of living. Conventionally, aging is associated with “loss of vitality” and the “desperate need to retain older abilities.” In contrast to these concepts, eastern views center around acceptance, “letting go” and aging with a greater sense of purpose. Traversing loneliness with self-esteem is viewed over a consistent resistance against loneliness. Self-acceptance, wisdom, and understanding the processes of emotional aging can foster hope and resilience which help navigate the inevitable loneliness that may arise in old age due to a multitude of factors. Spirituality has various intersections with mental well-being, however, it is often considered to be an esoteric concept. In this paper, we provide an Indian understanding of accepting and dealing with loneliness through the daily implementation of spiritual practices in life as well as mental health interventions. The four ashramas of Hinduism are discussed with special relevance to Vanaprastha Ashrama (forest-dweller), which signifies renunciation and acceptance associated with aging. The actionable areas with respect to spirituality and its philosophical underpinnings in mitigating loneliness in older people are also highlighted.
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Validated scales for substance use disorders in the geriatric population: A scoping review p. 70
Siddharth Sarkar, Esha Sood, Roshan Bhad, Ashwani Mishra
Substance use disorders in the elderly population can be assessed through scales and questionnaires. These scales are used for not only screening for substance use disorders but also for assessment for improvement with time and/or intervention. Validity parameters of these scales help us know how do they perform during application in the clinical or community setting. The objective of the review was to (1) review available validated screening tools for substance use disorders, (2) summarize elderly-focused studies, and (3) provide recommendations for use in clinical care. We aimed to review the validated scales of substance use disorders in the geriatric population. We looked at PubMed and Web of Science databases for identifying English language peer-reviewed publications that reported at least one validity parameter for scale in geriatric patients with substance use disorders. We identified 22 studies, with majority of them focusing on alcohol use disorder. Alcohol Use Disorder Identification Test and Cut Down, Annoyed, Guilty, and Eye-Opener Questionnaire (CAGE) were the most common scales used in the population. While most of the studies reported acceptable area under receiver operator curve, sensitivity, and specificity, some of the studies reported lower sensitivity/specificity at optimal cutoff. Validity parameters of various scales have been assessed in the geriatric population. Using suitable cutoffs, they can be useful in the screening of elderly individuals with substance-related problems, so that due evaluation and care can be provided. More instruments need to be assessed for validity to diagnose tobacco use disorders, benzodiazepine use disorders, and other substance use disorders.
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Cariprazine for late-life psychiatric illness: A review on therapeutic potential and challenges p. 77
Shiva Shanker Reddy Mukku, Ravi Kumar Nadella, Sumanth Ediga Kornapalli
Clinicians often face many challenges in the pharmacological treatment of late-life psychiatric illness especially while choosing an antipsychotic drug. The choice of antipsychotic is mostly guided by the extension of evidence from the adult population and tolerability. In India, based on evidence commonly prescribed antipsychotic drugs for older adults are quetiapine (QTP) followed by olanzapine (OLZN) and risperidone. Cariprazine is a newer antipsychotic that was recently launched in India. It is a novel mechanism of action at D3 receptors is known to have antidepressant and procognitive action in addition to the antipsychotic effects which is desirable in geriatric population. It can be a potential option as an add-on drug in late-life depression in addition to the existing aripiprazole and OLZN. The treatment of late-life mania and very late-onset schizophrenia is limited by the paucity of studies, with randomized control studies done only on QTP and amisulpride, respectively. Cariprazine can be considered in late-life psychotic disorders with the evidence available from its efficacy studies in adult patients. Merits of cariprazine are favorable metabolic profile, cardiac safety, and procognitive action. Demerits include extrapyramidal symptoms and fluctuations in blood pressure. Slower titration and monitoring for akathisia are recommended. There is a need for controlled studies in older adults with cariprazine to get better informed about its efficacy and safety.
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Neuroprotective effects of phytoestrogens: A potential alternative to estrogen therapy in Alzheimer's disease patients p. 83
Varsha Baweja, Himanshu , Akreti Tandon, Muskan Goyal, Ruby Mishra, Manasi Deshpande
Alzheimer's disease (AD) is classified as an age-related neuro-degenerative disorder leading to loss of memory and decline in cognitive abilities, often characterized as dementia. According to the WHO report 2020, out of 50 million people battling with dementia worldwide, 60%–70% cases account for AD. Some researchers have reported two to three times higher incidence of AD among women than men and further confirmed that postmenopausal women are more prone to AD than healthy men of the same age. This hints at the potential neuroprotective role of estrogen hormone, whose level drops to <30 pg/mL postmenopause. Several epidemiological studies also suggest early postmenopausal use of estrogens may contribute to the prevention, attenuation, or even delay in the onset of AD. Collectively, this evidence supports the further development of estrogen-like compounds for the treatment and prevention of AD, with a rising interest in phytoestrogens as potential interventions with lower side effects. This review highlights multiple pathways of estrogen-mediated neuroprotection against neurodegenerative diseases like AD and discusses the role of selective estrogen receptor molecules mainly phytoestrogens, in AD progression so that latter can be considered and used as an alternate therapy for treating Alzheimer patients.
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The complex conundrum of geriatric depression and dementias: Revisiting the clinical ambiguity p. 93
Sanchari Mukhopadhyay, Debanjan Banerjee
Late-life depression (LLD), mild cognitive impairment (MCI), and dementia are clinically distinct yet interrelated disease constructs, wherein LLD can be a prodrome, risk factor, comorbidity, or consequence of MCI and dementia. There is considerable prevalence of depression in those with MCI or dementia, and vice versa, with maximum evidence in Alzheimer's disease. These intersections often form one of the most confusing aspects of psychogeriatric practice, leading to under-detection and mismanagement of depression, thus leading to incomplete recovery in most cases. This article focuses on this clinical ambiguity in daily practice, reviews the clinico-investigative pointers for the LLD–dementia intersection, and puts forward clinical and research recommendations in view of the available evidence. Although there is conflicting evidence regarding the cause–effect relationship between LLD, MCI, and dementia, it is likely that these constructs share some common pathological processes and are often associated with each other within a longitudinal clinical continuum. This is a linear yet complex bidirectional association: either the comorbid depression exaggerates preexisting cognitive deficits or chronic persistent depression eventually leads to major neurocognitive disorders, not to mention depression as a part of behavioral and psychological symptoms of dementia, which often impairs quality of life and psychosocial morbidity. Thus, a comprehensive approach, including tailored history, neuropsychiatric examination, and relevant investigations, is necessary for assessing the differentials, with a sound clinical understanding being vital to the process. Depression, if suspected, must be treated adequately with longitudinal neuropsychological reviews. Future research warrants elucidating precision biomarkers unique to these clinicopathological entities.
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A study of quality of sleep, quality of life, and cognition in elderly: Healthy control, depressed and with mild neurocognitive disorder p. 107
Samiksha Jadhav, Alka Anand Subramanyam, Nitin B Raut, Shipra Singh
Background: Sleep plays a vital role in maintaining optimum physical and mental functioning and can be implicated in affecting the quality of life (QOL) and cognition in elderly population. This study aims to assess quality of sleep, QOL and to assess the effect of quality of sleep on QOL and cognition in elderly population Materials and Methods: A cross-sectional study was done in elderly population in which 30 were healthy control, 30 depressed, and 30 with mild neurocognitive disorder (NCD) who were assessed using Pittsburg Sleep Quality Index, World Health Organization QOL (WHOQOL)-BREF, Geriatric Depression Scale-Short form, and Addenbrooke's Cognitive Examination Scale-Revised (ACE-R). Statistical analysis was done using SPSS 20 software using descriptive methods and Pearson's correlation test. Results: Mean Pittsburgh Sleep Quality Index (PSQI) score was the lowest and mean WHOQOL-BREF score highest in healthy control compared to elderly with mild NCD and depression, the difference being statistically significant in both cases (P < 0.01). PSQI scores have negative correlation with the ACE-R scores when studied in healthy control group (P < 0.05, r = −0.136) and WHOQOL-BREF domain scores overall (P < 0.01 r = −0.485, −0.497, −0.350, −0.475). Conclusion: Quality of sleep in elderly with depression and mild NCD is lower as compared to healthy control. Sleep may affect QOL and cognition in elderly and thus it would be essential to screen and identify sleep-related issues and intervene early.
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Views of the elderly living in old-age homes on psychosocial care needs p. 113
Manjunatha Shivarudraiah, Thirumoorthy Ammapattian, Sojan Antony, Sivakumar Palanimuthu Thangaraju
Background: Older adults are likely to experience psychological and social problems due to decline in physical strength, increased health issues, inadequate financial resources, and family dynamics. In this context, they need psychosocial care services to handle such challenges. Particularly, inmates of old-age homes are more vulnerable to experience such challenges as they are away from the family care. In this background, knowing their views on psychosocial care needs while living in old-age homes is significant to improve old-age home-based care. The aim of this study is to explore the psychosocial care needs expressed by the inmates of old-age homes. Materials and Methods: Inmates of old-age homes were selected using purposive sampling. A total of twenty residents out of four old-age homes of Bengaluru Metropolitan City were interviewed using a semi-structured interview guide. The qualitative content analysis has been carried out to identify core psychosocial care needs out of the text data. Results: Three themes, namely “health-care needs,” “concerns regarding the behavior of the staff,” and “mental health needs,” are emerged. Conclusion: The current study findings provide insiders' views and highlight the importance of psychosocial care services to address their needs at every old-age home.
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Cognitive status of older adults with diabetes mellitus, hypertension, and dyslipidemia on Hindi Cognitive Screening Test and Saint Louis University Mental State p. 118
Rakesh Kumar Tripathi, Shailendra Mohan Tripathi, Nisha Mani Pandey, Anamika Srivastava, Kauser Usman, Wahid Ali, Sarvada C Tiwari
Background: Hindi cognitive screening test (HCST) and Saint Louis University Mental Status (SLUMS) Examination both claim that they are bias-free cognitive screening tests. HCST is highly sensitive and specific in screening Indian older adults. However, SLUMS is more comprehensive in terms of assessing visuospatial and memory functions. The present study presents and compare cognitive status of older adults with diabetes mellitus (DM), hypertension (HT), and dyslipidemia (DL) on HCST and SLUMS. Methods: The sample comprised of 150 older adults ≥60 years included in a consecutive series. Participants and their family members, giving written informed consent, residing permanently in central catchment areas Chowk, Lucknow, constituted the study sample. Semistructured sociodemographic details and medical history proforma, Socioeconomic Status (SES) Scale, General Health Questionaire – 12, SLUMS and HCST were administered. Blood pressure was measured by Medical Research Assistant. Biochemical investigations for DM and DL were carried out. Participants were categorized into two groups: (1) case groups (112): DM only + HT only + DL only and (2) control group (38): Without discernable abnormality of physical illness on the basis of invesigations. Data were analyzed using percentage, mean, standard devitation SD, Chi-square, and t-test. Results: There was a statistically significant difference on cognitive status between control and DM group on recall, reading, copying (P < 0.05 level), and on writing (P < 0.01) on HCST. A statistically significant difference was also found in writing (P < 0.01) between control and HT group. A statistically significant difference was found between control and DL on recall (P < 0.05) and writing (P < 0.01). According to SLUMS control and DM group differ significantly (0.01) for delayed recall and with HT and DL group on visuospatial function. Conclusion: Cognitive status of older adults with DM, HT, and DL was found to be significantly impaired on specific domains as compared to the control group.
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Life skill training workshop in geriatric mental health for postgraduate students: An appraisal p. 126
Nisha Mani Pandey, Rakesh Kumar Tripathi, Samyak Tiwari
Background: Management of mentally ill elderly is a challenging task. Due to the lack of awareness, training opportunities in the course curriculum, and nil to negligible knowledge/ understanding/ exposures, allied mental health professionals are hardly available in geriatric mental health (GMH). Awareness generating orientation/ skill development workshops/ seminars/ webinars/ conferences may develop the interest in the young generations, which further may help in generating human resources in the subject. The present article aims to provide a snapshot of the Life Skill Training (LST) workshop developed for psychology students and discusses its effectiveness. Materials and Methods: The authors had an opportunity to organize and facilitate orientation workshop named as “life skill training in GMH for the students of psychology in Varanasi. A total of 86 students had participated in two independent workshops. All participants' self-rated appraisal was obtained on a five-point scale (ranging from very poor to very good) for all ten core life skills as laid out by the World Health Organization. The workshop was conducted by applying the tools such as imagination, reflection, communication, presentation, problem-solving, critical thinking, and sharing. The pre-post assessment was done, and qualitative feedback was received from the participants. Results: The results reveal that participants observed betterment in self on each life skill as the obtained value of mean scores after the workshop was found to be slightly more on each of the core life skills. Conclusion: The orientation workshop sensitizes the students regarding the issues related to the field, which may allow them to pursue the subject further.
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Potentially inappropriate medication with syndrome of inappropriate antidiuretic hormone secretion and gastrointestinal bleed in an older adult presenting as a psychiatric emergency p. 130
Migita M D’cruz, Ankit Sharma, Dinakaran Damodharan
Geriatric patients are commonly exposed to multimorbidity, polypharmacy, and potentially inappropriate medication use, with prevalence increasing over time. We seek to illustrate this risk to older adults through a case report of an older woman presenting with irritability to psychiatric emergency services in the context of potentially inappropriate medication use. On evaluation, the irritability was found to be associated with hip pain due to osteoarthritis and gastric irritation due to the use of analgesics, antacids, and other micronutrient supplements. She was diagnosed with analgesic-induced syndrome of inappropriate antidiuretic hormone production with dilutional hyponatremia and hypochloremia, iatrogenic upper gastrointestinal mucosal ulceration with melena and anemia due to blood loss, analgesic-induced coagulation disorder, acute kidney injury, impending hepatic injury, and hyponatremia-induced second-degree atrioventricular block. She recovered with treatment rationalization, pain management, and supportive care. We wish to highlight that an innocuous presentation such as increased irritability in the absence of a mental illness in an older adult may often overlie multimorbidity and potentially inappropriate medication use. We would also like to use this case report to illustrate the barriers to comprehension and compliance that may occur in geriatric patients, with the need for frequent pharmacological assessments including prescription checks and pill counts.
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Marked cognitive decline following COVID-19 infection p. 133
Sandeep Grover, Aseem Mehra, Swapnajeet Sahoo, Parvaiz Alam
COVID-19 pandemic has influenced humans in many ways. In terms of mental health outcomes, many studies across the globe have shown a high prevalence of anxiety and depression among persons suffering from the acute COVID infection and during the post-COVID infection phase. Additionally, studies have also shown a high prevalence of cognitive deficits as part of the long COVID. In this report, we present a 63-year-old male who developed marked cognitive impairment after COVID-19 infection.
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The person is not the disease – Revisiting Alzheimer's dementia after 120 years p. 136
Migita Michael D’Cruz, Debanjan Banerjee
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