Discontinuation Rate of Newly Prescribed Donepezil in Alzheimer’s Disease Patients in Asia

Background@#and Purpose The rate of donepezil discontinuation and the underlying reasons for discontinuation in Asian patients with Alzheimer’s disease (AD) are currently unknown. We aimed to determine the treatment discontinuation rates in AD patients who had newly been prescribed donepezil in routine clinical practice in Asia. @*Methods@#This 1-year observational study involved 38 institutions in seven Asian countries, and it evaluated 398 participants aged 50–90 years with a diagnosis of probable AD and on newly prescribed donepezil monotherapy. The primary endpoint was the rate of donepezil discontinuation over 1 year. Secondary endpoints included the reason for discontinuation,treatment duration, changes in cognitive function over the 1-year study period, and compliance as assessed using a clinician rating scale (CRS) and visual analog scale (VAS). @*Results@#Donepezil was discontinued in 83 (20.9%) patients, most commonly due to an adverse event (43.4%). The mean treatment duration was 103.67 days in patients who discontinued. Among patients whose cognitive function was assessed at baseline and 1 year, there were no significant changes in scores on the Mini-Mental State Examination, Montreal Cognitive Assessment, and Trail-Making Test–Black and White scores, whereas the Clinical Dementia Rating score increased significantly (p<0.001). Treatment compliance at 1 year was 96.8% (306/316) on the CRS and 92.6±14.1% (mean±standard deviation) on the VAS. @*Conclusions@#In patients on newly prescribed donepezil, the primary reason for discontinuation was an adverse event. Cognitive assessments revealed no significant worsening at 1 year, indicating that continuous donepezil treatment contributes to the maintenance of cognitive function.

Discontinuation Rate of Newly Prescribed Donepezil in Alzheimer’s Disease Patients in Asia

Background@#and Purpose The rate of donepezil discontinuation and the underlying reasons for discontinuation in Asian patients with Alzheimer’s disease (AD) are currently unknown. We aimed to determine the treatment discontinuation rates in AD patients who had newly been prescribed donepezil in routine clinical practice in Asia. @*Methods@#This 1-year observational study involved 38 institutions in seven Asian countries, and it evaluated 398 participants aged 50–90 years with a diagnosis of probable AD and on newly prescribed donepezil monotherapy. The primary endpoint was the rate of donepezil discontinuation over 1 year. Secondary endpoints included the reason for discontinuation,treatment duration, changes in cognitive function over the 1-year study period, and compliance as assessed using a clinician rating scale (CRS) and visual analog scale (VAS). @*Results@#Donepezil was discontinued in 83 (20.9%) patients, most commonly due to an adverse event (43.4%). The mean treatment duration was 103.67 days in patients who discontinued. Among patients whose cognitive function was assessed at baseline and 1 year, there were no significant changes in scores on the Mini-Mental State Examination, Montreal Cognitive Assessment, and Trail-Making Test–Black and White scores, whereas the Clinical Dementia Rating score increased significantly (p<0.001). Treatment compliance at 1 year was 96.8% (306/316) on the CRS and 92.6±14.1% (mean±standard deviation) on the VAS. @*Conclusions@#In patients on newly prescribed donepezil, the primary reason for discontinuation was an adverse event. Cognitive assessments revealed no significant worsening at 1 year, indicating that continuous donepezil treatment contributes to the maintenance of cognitive function.

Clinical Aspects of Neurobehavioral Symptoms of Dementia

Neurobehavioral symptoms of dementia (NBSD) are very common and are significant symptoms of the illness, contributing most to caregiver burdens and often resulting in premature institutionalization of the person with dementia. The main symptoms of NBSD are anxiety, depression, delusions, and hallucinations. NBSD produce significant problems for both patients and caregivers. The pathophysiology of NBSD is determined by genetic, structural, or environmental factors. Therefore, treatment of NBSD requires continuous and organic cooperation between patients, caregivers, social environments, and doctors. Therefore, it is important for neurologists, who mainly view NBSD for dementia patients, to increase their understanding of these more comprehensive areas as well as the latest insights and treatments to help patients and caregivers.

The louder the bigger: A case of jugular phlebectasia in a child

@#Jugular phlebectasia has been increasingly recognised with the advent of non-invasive diagnostic methods. Phlebectasia differs from varix, as it is an abnormal outward dilatation of a vein without tortuosity. It presents as a soft, compressible mass, apparent upon straining or execution of the Valsalva maneuver. The differentials for neck masses are broad, but if the swelling appears on the Valsalva maneuver, the type of mass narrows down to a laryngocele, superior mediastinal mass or phlebectasia. A simple non-invasive investigation, such as ultrasonography, is used as a diagnostic tool. We report a case of jugular phlebectasia that was suspected clinically and confirmed via ultrasound to be a vascular lesion which changed its size upon straining.

Relationship between Quality of Life and Nutritional Status in Colorectal Cancer Patients Undergoing Chemotherapy

Introduction: Malnutrition is associated with poorer outcomes following treatment for colorectal cancer (CRC). This study evaluates the relationship between nutritional status using scored Patient Generated-Subjective Global Assessment (PG-SGA) with the validated European Organisation for Research and Treatment of Cancer questionnaire (EORTC-QLQ C30) which consists of five functional scales, three symptoms scales and one item of global health/quality of life (QOL). Methods: A total of 42 CRC patients at oncology outpatient clinics from two hospitals in Malaysia participated in the study from March 2011 to March 2012. The participants were classified as either well-nourished (PG-SGA A) or malnourished (PG-SGA B and C). Results: The majority of patients were Chinese, male, with a mean age of 57.1 ?± 9.8 years and had been diagnosed with stage 2 CRC. Well-nourished patients had statistically significantly better QOL scores on symptom scales: fatigue (p<0.001), nausea and vomiting (p<0.05), and pain (p<0.001) compared to malnourished patients. PG-SGA was strongly correlated with the main domains of the QOL: global health status (r = -0.395, p<0.05), fatigue (r = 0.816, p<0.001), nausea and vomiting (r = 0.730, p<0.001) and pain (r= 0.629, p<0.001). The better the nutritional status (lower total mean score of PG-SGA), the higher the QOL (high mean score of global health status). Conclusion: The scored PG-SGA is suitable for use as a nutrition assessment tool to identify malnutrition and it is associated with QOL among this population

Psychometric Properties of Alzheimer's Disease Assessment Scale-Cognitive Subscale for Mild Cognitive Impairment and Mild Alzheimer's Disease Patients in an Asian Context

<p><b>INTRODUCTION</b>The purpose of the current study is to assess the psychometric properties of Alzheimer's Disease Assessment Scale-Cognitive subscale (ADAS-Cog) on patients with mild cognitive impairment (MCI) and mild Alzheimer's disease (AD) in a multicultural Asian context.</p><p><b>MATERIALS AND METHODS</b>Sixty-four mild AD patients (mean age ± SD; 72.24 ± 7.88 years), 80 MCI patients (66.44 ± 7.45 years) and 125 healthy controls (HCs) (61.81 ± 6.96 years) participated in the study. Participants underwent a clinical interview and serial neuropsychological testing. ADAS-Cog total and subtest scores were compared across the 3 groups. Receiver operating characteristics (ROC) analysis were performed and sensitivity, specificity, positive predictive values (PPVs) and negative predictive values (NPVs) were calculated.</p><p><b>RESULTS</b>Patients with MCI attained significantly worse neuropsychological test scores than healthy controls but significantly better results than patients with mild AD on ADAS-Cog total score, subtest items, and the delayed recall item (P <0.001). The best cutoff score to differentiate between MCI and HC was ≥4 (sensitivity = 0.73, specificity = 0.69, PPV = 0.90, NPV = 0.40), while the best cutoff score to distinguish between MCI and mild AD was ≥12 (sensitivity = 0.86, specificity = 0.89, PPV = 0.99, NPV = 0.32). Evidence of internal consistency of the ADAS-Cog (Cronbach α = 0.85) as well as convergent validity with the Mini-Mental State Examination (MMSE) (ρ = -0.75) and Montreal Cognitive Assessment (MoCA) (ρ = -0.81) (both P <0.001) was also found.</p><p><b>CONCLUSION</b>The ADAS-Cog which is widely used in clinical trials is applicable to the Asian cohort. It is useful in the detection of MCI and mild AD as well as in distinguishing these 2 conditions.</p>

Improving the Nutritional Status of Patients with Colorectal Cancer Undergoing Chemotherapy through Intensive Individualised Diet and Lifestyle Counselling

Introduction: Malnutrition is common among patients with cancer and it is also associated with their negative health outcomes. Generally, cancer patients undergoing chemotherapy have a high risk of malnutrition, secondary to both the disease and the treatment. It is important that patients maintain a good nutritional status to improve the effects, and minimise the side effects of cancer treatment. A good nutritional status should be maintained for patients through nutritional intervention during cancer treatment. There appears to be no published studies on the effects of intense dietary counselling versus usual dietary care on the nutritional status of colorectal cancer (CRC) patients undergoing chemotherapy alone. Furthermore, there have been no randomised controlled trials (RC1) undertaken in Malaysia, where CRC is increasing. It is therefore important to undertake a RCT of a dietary and lifestyle counselling intervention of CRC outpatients undergoing chemotherapy. Methods: The intervention study was an open (masking not used), prospective, and Rcr to examine the effects of intensive individualised dietary and lifestyle counselling on dietary intake and nutritional status in CRC patients undergoing chemotherapy. It was designed as an 8-week program of intensive, individualised dietary and lifestyle counselling followed up with another 8-week post-intervention period without dietary and lifestyle counselling, and compared to a control arm given the usual care. A total of forty-two participants took part in this study and were randomised into two groups, namely, the intervention group (IG) (n=22) and the control group(CG) (n=20) at Kuala Lumpur Hospital and SelayangHospital, Malaysia. Results In this study, 67% of CRC patients were malnourished at baseline. In the IQ the prevalence of malnutrition dropped from 72.7% at baseline to 27.3% eight weeks after the intervention. This repesents a large, and clinically meaningful shift. In the CG, the prevalence of malnutrition, or at risk of malnutrition, was still at 75% at the end of the sixteen weeks. Conclusion: Intensive, individualised dietary and lifestyle counselling resulted in improved nutritional status in patients with CRC undergoing chemotherapy.

Improving the Nutritional Status of Patients with Colorectal Cancer Undergoing Chemotherapy through Intensive Individualised Diet and Lifestyle Counselling

Introduction: Malnutrition is common among patients with cancer and it is also associated with their negative health outcomes. Generally, cancer patients undergoing chemotherapy have a high risk of malnutrition, secondary to both the disease and the treatment. It is important that patients maintain a good nutritional status to improve the effects, and minimise the side effects of cancer treatment. A good nutritional status should be maintained for patients through nutritional intervention during cancer treatment. There appears to be no published studies on the effects of intense dietary counselling versus usual dietary care on the nutritional status of colorectal cancer (CRC) patients undergoing chemotherapy alone. Furthermore, there have been no randomised controlled trials (RC1) undertaken in Malaysia, where CRC is increasing. It is therefore important to undertake a RCT of a dietary and lifestyle counselling intervention of CRC outpatients undergoing chemotherapy. Methods: The intervention study was an open (masking not used), prospective, and Rcr to examine the effects of intensive individualised dietary and lifestyle counselling on dietary intake and nutritional status in CRC patients undergoing chemotherapy. It was designed as an 8-week program of intensive, individualised dietary and lifestyle counselling followed up with another 8-week post-intervention period without dietary and lifestyle counselling, and compared to a control arm given the usual care. A total of forty-two participants took part in this study and were randomised into two groups, namely, the intervention group (IG) (n=22) and the control group(CG) (n=20) at Kuala Lumpur Hospital and SelayangHospital, Malaysia. Results In this study, 67% of CRC patients were malnourished at baseline. In the IQ the prevalence of malnutrition dropped from 72.7% at baseline to 27.3% eight weeks after the intervention. This repesents a large, and clinically meaningful shift. In the CG, the prevalence of malnutrition, or at risk of malnutrition, was still at 75% at the end of the sixteen weeks. Conclusion: Intensive, individualised dietary and lifestyle counselling resulted in improved nutritional status in patients with CRC undergoing chemotherapy.

Role of cerebrovascular risk factors in dementia

With the rapid increase in the prevalence of dementia worldwide there has been significant research into modifiable risk factors for dementia. In this regard cerebrovascular diseases (CVD) represent a potential therapeutic target in the fight against the epidemic of dementia. Both large vessel CVD and small vessel disease in the form of chronic lacunes, white matter hyperintensity, microbleeds, and perivascular spaces have been strongly associated with the risk of developing dementia. These CVD factors may initiate or accelerate the amyloid and tau cascades resulting in greater rates of neurodegeneration and dementia. Understanding the precise mechanisms for the interaction between CVD and neurodegeneration will allow development of potential interventional targets. These CVD risk factors may be of particular relevance to the Asian population where a high burden of small vessel CVD has been demonstrated in Asian patients with dementia

Prophylactic effect of Mucuna pruriens Linn (velvet bean) seed extract against experimental Naja sputatrix envenomation: Gene expression studies.

Mucuna pruriens is widely used in traditional medicine for treatments of various diseases. In certain region of Nigeria, the seed is used as oral prophylactics for snakebite. Rats pretreated with the aqueous extract from M. pruriens seed (MPE) were protected against the lethal effects of Naja sputatrix (Javan spitting cobra) venom [Tan et al., J Ethnopharmacol, 123 (2009) 356]. The pretreatment also protected against venom-induced histopathological changes in rat heart. To contribute to the understanding of the mechanism of cardio-protective action, the present study examined the effects of MPE-pretreatment on gene expression profile of rat heart as well as effect of MPE-pretreatment on N. sputatrix venom-induced gene expression alterations in rat heart. The gene expression profiles were examined by microarray analysis and verified by real time PCR. The results showed that pretreatment with MPE caused 50 genes in the rat heart substantially up-regulated of which 19 were related to immune responses, 7 were related to energy production and metabolism. The up-regulation of genes related to energy metabolism probably plays a role in maintaining the viability of the heart. Four other genes that were up-regulated (alpha synuclein, natriuretic peptide precursor, calsequestrin and triadin) were involved in the maintenance of homeostasis of the heart or maintaining its viability, thereby contributing to the direct protective action. The results demonstrated that protective effect of MPE pretreatment against snake venom poisoning may involve a direct action on the heart.

Stages of change to increase fruit and vegetable intake and its relationships with fruit and vegetable intake and related psychosocial factors

BACKGROUND/OBJECTIVES: Understanding individual's intention, action and maintenance to increase fruit and vegetable intake is an initial step in designing nutrition or health promotion programs. This study aimed to determine stages of change to increase fruit and vegetable intake and its relationships with fruit and vegetable intake, self-efficacy, perceived benefits and perceived barriers. SUBJECTS/METHODS: This cross-sectional study was conducted among 348 public university staff in Universiti Putra Malaysia. A pre-tested self-administered questionnaire and two days 24-hour diet recall were used. RESULTS: Half of the respondents (50%) were in preparation stage, followed by 43% in action/maintenance, 7% in pre-contemplation/contemplation stages. Respondents in action/maintenance stages had significantly higher self-efficacy (F = 9.17, P < 0.001) and perceived benefits (F = 5.07, P < 0.01) while respondents in pre-contemplation/contemplation and preparation stages had significantly higher perceived barriers (F = 4.83, P < 0.05). Perceived benefits tend to outweigh perceived barriers pre-ceding to taking action. Self-efficacy is important in motivating individuals to increase fruit and vegetable intake as self-efficacy and perceived barriers crossed over between preparation and action/maintenance. Respondents in action/maintenance stages had the highest adjusted mean serving of fruit and vegetable intake (F = 4.52, P < 0.05) but the intake did not meet recommendation. CONCLUSION: Intervention strategies should emphasize on increasing perceived benefits and building self-efficacy by providing knowledge and skills to consume a diet high in fruits and vegetables in order to promote healthy changes in having high fruit and vegetable intake.

Overview of Dementia and Diagnosis of Dementia

Dementia is a syndrome characterised by cognitive, behavioural and neurological deficits. Both neurodegenerative and non-neurodegenerative conditions can result in dementia. Neurodegenerative diseases include diseases such as Alzheimer’s disease, Frontotemporal Dementia and Dementia with Lewy body, while nonneurodegenerative conditions include conditions such as vascular dementia and normal pressure hydrocephalus. The prevalence of dementia is on a rising trend with the rapidly ageing population in Singapore. Early diagnosis of dementia is important to allow timely pharmacological and non-pharmacological interventions. A thorough history, cognitive evaluation along with suitable investigational studies is necessary for early diagnosis. The ability to diagnose dementia at the earliest stages has been greatly improved with the use of biomarkers such as medial temporal atrophy on MR imaging and cerebrospinal fluid beta amyloid levels. A 4-step approach to dementia evaluation, incorporating local data, where possible can be used: The first step requires the exclusion of delirium as the cause of the forgetfulness or confusion; the second step involves establishing the diagnosis of dementia; the third step assesses for the behavioural, functional and social problems associated with dementia; and the final step, with the use of a focused history, physical examination, investigations and selected use of neuroimaging, attempts to establish the aetiological diagnosis of the dementia. The management of dementia requires a multidisciplinary approach. While acetyl cholinesterase inhibitors and NMDA antagonist can slow cognitive deterioration, research for newer disease modifying drugs which target the underlying pathology is ongoing. Research into nonpharmacological interventions such as cognitive training is also on-going.

Effectiveness of Montreal Cognitive Assessment for the diagnosis of mild cognitive impairment and mild Alzheimer's disease in Singapore

<p><b>INTRODUCTION</b>Mild cognitive impairment (MCI) is an important clinical entity with significant management implications. However, traditional screening tools lack the sensitivity needed to detect amnestic MCI (MCI-A). Montreal Cognitive Assessment (MoCA) has yet to be validated for the diagnosis of MCI in a multiracial society such as Singapore. We thus aimed to study the effectiveness of MoCA for the diagnosis of MCI-A in the Singapore population.</p><p><b>METHODS</b>Data on patients with MCI-A and mild Alzheimer's disease (AD) was obtained from a prospectively collected clinical database between January 2008 and January 2011. Patients with no cognitive impairment (NCI) were recruited from among the spouses and friends of patients attending the memory clinic.</p><p><b>RESULTS</b>There were a total of 212 participants (103 NCI, 49 MCI-A, 60 mild AD). For the diagnosis of MCI-A, a MoCA score of < 26 for patients with ≤ 10 years of education, and a score of < 27 for patients with > 10 years of education provided a sensitivity of > 94%. For the diagnosis of mild AD, a MoCA score of < 24 for patients with ≤ 10 years of education, and a score of < 25 for patients with > 10 years of education provided a sensitivity of > 85%.</p><p><b>CONCLUSION</b>In the Singapore population, we recommend cutoff scores of 26/27 and 24/25 be used to detect MCI-A and mild AD, respectively, when using MoCA. For patients with ≤ 10 years of education, a +1 point correction is needed.</p>

Assessing the children's views on foods and consumption of selected food groups: outcome from focus group approach

The food choices in childhood have high a probability of being carried through into their adulthood life, which then contributes to the risk of many non-communicable diseases. Therefore, there is a need to gather some information about children's views on foods which may influence their food choices for planning a related dietary intervention or programme. This paper aimed to explore the views of children on foods and the types of foods which are usually consumed by children under four food groups (snacks, fast foods, cereals and cereal products; and milk and dairy products) by using focus group discussions. A total of 33 school children aged 7-9 years old from Selangor and Kuala Lumpur participated in the focus groups. Focus groups were audio-taped, transcribed and analyzed according to the listed themes. The outcomes show that the children usually consumed snacks such as white bread with spread or as a sandwich, local cakes, fruits such as papaya, mango and watermelon, biscuits or cookies, tea, chocolate drink and instant noodles. Their choices of fast foods included pizza, burgers, French fries and fried chicken. For cereal products, they usually consumed rice, bread and ready-to-eat cereals. Finally, their choices of dairy products included milk, cheese and yogurt. The reasons for the food liking were taste, nutritional value and the characteristics of food. The outcome of this study may provide additional information on the food choices among Malaysian children, especially in urban areas with regard to the food groups which have shown to have a relationship with the risk of childhood obesity.

Relationship between Nutritional Status, Physical Activity and Quality of Life among Gastrointestinal Cancer Survivors

Introduction: The objective of this study was to determine the relationship between nutritional status, physical activity and quality of life among gastrointestinal cancer survivors. Methods: A cross-sectional study was conducted among gastrointestinal cancer survivors attending the oncology outpatient clinic in Hospital Selayang, Malaysia. Results: A total of 70 gastrointestinal cancer survivors with a mean age of 52.54 ± 14.59 years (95% CI: 47.48 – 57.60) were included in this study. Results showed that 40% of the patients were classified as having low physical activity. The mean Patient Generated Subjective Global Assessment (PGSGA) score was 10.27 ± 7.36 (95% CI: 8.23 – 12.31) and nearly half the patients (48.6%) were identified as severely malnourished (Stage C). Mean Gastrointestinal Quality of Life Index (GQLFI) score was 103.57 ± 23.85 (95% CI:92.94 -114.20), and about 24.3% of the patients were classified as having a low quality of life. Pearson’s correlation test showed a highly significant negative relationship between nutritional status and quality of life (r=-0.661, p<0.001) indicating the better the nutritional status (low total mean score of PGSGA), the better the quality of life of the survivors (high total mean score of GQLFI). There was a significant negative relationship between physical activity level and nutritional status score (r=-0.309, p<0.01), indicating the higher the physical activity level of the patients (high MET-min/week), the better their nutritional status (low total mean score of PGSGA). Conclusion: This study shows a significant relationship between nutritional status, physical activity and quality of life among gastrointestinal cancer survivors. Those low in nutritional status have a low quality of life while survivors with higher nutritional status have a better quality of life.