Risk factors for dementia and impaired cognitive status in Thai elderly.

OBJECTIVE: To examine the association of physical and biochemical risk factors for dementia and cognitive status in an urban population based Thai elderly. MATERIAL AND METHOD: This study was part of an integrated health research project from 1997 to 1999. Subjects were 550 elders who lived in a community within 10 km from Siriraj Hospital, Bangkok, Thailand. They were 55 years and older. Thai mental state examination (TMSE) was applied to all subjects as the screening test for dementia. Those who scored less than or equal to 24 out of 30 were categorised as having cognitive impairment or suspected of having dementia, and they were then examined in detail for the diagnosis of dementia using the DSM IV criteria. Blood pressure and body weight were recorded. Blood was drawn for biochemical and haematological analysis including the serology for syphilis and thyroid function test as the basic screening investigation for dementia. Descriptive data, expressed as the mean, standard deviation, Pearson Chi square and ANOVA tests were analysed with SPSS 9.0 in the study. RESULTS: Of 550 subjects, 261 (47.45%) were classified as the normal subjects group, 49 (8.91%) as the cognitively impaired group, and 240 (43.82%) as the dementia group. 377 subjects (68.55%) were female and the distribution of females in each subgroup ranged from 63.3-75.5 per cent. The mean age in the normal group was 67.47 +/- 6.05 years, the cognitively impaired group was 70.14 years and the dementia group was 69.63 +/- 9.21 years. Systolic blood pressure (BP), diastolic BP, serum cholesterol, SGOT, GGT, serum albumin, haemoglobin, MCHC, neutrophil counts and weight were statistically significant factors that were associated with cognitive status. Both systolic and diastolic BP were high in the higher cognitive status group. Serum albumin, serum cholesterol levels and body weight were also higher in the high cognitive status group. CONCLUSION: This study demonstrated an association between nutritional status and cognitive status in Thai elderly. Poorer nutritional factor in lower cognitive function individuals might explain a lower of both systolic and diastolic BP in the dementia subjects compared to the healthy subjects.

Cognitive status in the community dwelling Thai elderly.

OBJECTIVE: To survey the prevalence of cognitive impairment in the elderly and to estimate the prevalence of dementia in the community dwelling Thai population. To assess the psychometric property of Thai Mental State Examination (TMSE). MATERIAL AND METHOD: We conducted a countrywide survey of 3,177 Thai elderly who were 60 years old and over from 1995 to 1997. Medical history and ability to carry out daily activities were taken by trained medical personnel. Thai Mental State Examination (TMSE) was used for cognitive study. Every elderly person involved in this study was examined by either an internist or a neurologist. Blood was taken for haematological and biochemical analysis. SPSS 6.0 was the main statistical analysis of the data. RESULTS: Three thousand one hundred and seventy seven elderly people were enrolled in this study, thirty eight point eight per cent were male and sixty one point two per cent were female. There was correlation between age, education and TMSE (r=-0.345, r=0.473, p<0.001). We found no correlation between TMSE, mean arterial blood pressure (BP), systolic BP, diastolic BP, haematocrit, cholesterol, triglyceride, blood sugar and syphilitic serology. Multiple cut off points of TMSE was proposed to utilise the twenty fifth percentile in each five yearly age interval. Those who were under the 25th percentile of TMSE and had impaired daily activities were diagnosed as dementia. The prevalence of dementia was 9.88 percentiles in our study. CONCLUSION: Dementia is a common problem in the Thai elderly. As treatment has become available for several etiologies of dementia, early detection and assessment of dementia with a cognitive screening test are essential. Public education to distinguish between dementia and old age needs to be emphasised.

Experience of ApoE study in Thai elderly.

The association between ApoE E4 and dementia is reported in Alzheimer's disease and other dementia such as in multi-infarct dementia. OBJECTIVES: To examine the association between apolipoprotein E genotype (ApoE) and dementia in Thai elderly and patients to examine the alleles frequencies of ApoE in a Thai population. MATERIAL AND METHOD: Seventy-eight cases and ninety-four controls from a community based population were recruited. Their ages were all over 50 years. Dementia was diagnosed by DSM IV criteria. Blood was taken and stored for DNA extraction and for restriction enzyme analysis of ApoE genotype. Descriptive analysis and odds ratios from SPSS 9.0 program were used in this study. RESULTS: Alleles frequencies of ApoE E2, E, E4 in normal controls were 0.03, 0.80, 0.17 and alleles frequencies of ApoE E3, E4 in dementia subjects were 0.71 and 0.29, respectively. Odds ratios for dementia risk of apolipoprotein genes were as follows: 0.62 for ApoE E3 and 1.98 for ApoE E4. In this study, forty-two dementia subjects had Alzheimer's disease. Fifty nine point five per cent of Alzheimer's disease subjects carried ApoE E4 (positive predictive value is 0.60). CONCLUSION: Thai elderly carry ApoE genotype distribution similar to that reported in other ethnic groups. Bearing ApoE E4 gene increases the risk of developing dementia. The use of ApoE genotyping can only be a diagnostic adjunct for Alzheimer's disease.

Successful medical treatment of multiple cryptococcomas: report of a case and literature review.

We report a 35-year-old man diagnosed as having CNS cryptococcosis with multiple cryptococcomas, presenting with headache, papilloedema and impaired mental function in a previously healthy man. Cerebrospinal fluid (CSF) examination revealed lymphocytic pleocytosis with low glucose level. Gram's stain, acid fast bacilli stain and Indian ink examination were all negative. CSF cryptococcal antigen was positive, however, several fungal cultures were negative. Early cranial CT scan showed focal cerebritis over the right temporal lobe while subsequent imaging studies showed multiple contrast-enhancing masses with severe surrounding brain oedema over bilateral frontoparietal areas. Brain biopsy showed cryptococcal granulomatous lesions. Treatment was successful with antifungal agents and steroids without surgical removal.

Epidemiology of stroke in the elderly in Thailand.

Epidemiology of stroke in the elderly in Thailand was conducted from August 1994 to October 1996. The total of 3,036 Thai elderly were included in this study. They represented the elderly population from four regions; Central Region (615 elderly, Nakhon Pathom Province), Northern Region (840 elderly, Lampang Province), North-Eastern Region (706 elderly, Sakon Nakhon Province), and Southern Region (857 elderly, Ranong Province). All elderly in these selected areas received general physical examinations and complete neurological examinations from neurologists. Demographic data concerning each individual was recorded by specially trained nurses. Data included age, sex, occupation, education, drug usage, alcohol, smoking and pre-existing diseases. Blood was taken from each subject for complete blood count, fasting blood sugar, cholesterol, triglyceride, high density lipoprotein cholesterol and VDRL. Data on physical examinations were recorded with particular attention to blood pressure, carotid bruit, cardiac murmurs, cardiac arrhythmia, speech, posture, gait, frontal lobe releasing signs, Babinski sign and focal neurological deficit. Thirty-four stroke patients were identified from 3,036 elderly (prevalence rate of 1.12 per cent). There were 12 stroke patients from Central Region (prevalence rate of 1.99 per cent), 5 from Northern Region (0.6 per cent), 4 from North-Eastern Region (0.6 per cent) and 13 from Southern Region (1.5 per cent). Hypertension was the main risk factor for stroke in this study whereas diabetes mellitus, smoking, alcohol consumption, hyperlipidemia and underlying heart diseases were insignificant risk factors. The prevalence of hypertension in Thai elderly was ranging from 16.7 to 47.2 per cent (criteria over 140/90 mmHg) or 6.1 to 24.8 per cent (criteria over 160/90 mmHg). Prevalence of smoking and alcohol consumption in Thai elderly ranged from 19.5 per cent (Sakon Nakhon) to 62.1 (Lampang) and 16.75 per cent (Nakhon Pathom) to 33.70 per cent (Lampang) respectively. Data from physical examinations revealed that dysarthria, hemiplegic gait and Babinski sign were the significant signs for diagnosis of stroke in the community setting. The prevalence of carotid bruit, cardiac murmur and cardiac arrhythmia were ranging from 1.3 to 1.8 per cent, 3.1-7.1 per cent and 0.8-1.4 per cent respectively. From this study, it can be concluded that stroke prevention is the best policy for stroke management. Stroke prevention measures should thus be aimed at the high risk elderly group. This is best achieved by identifying risk factors among them and then controlling these risk factors properly.

Botulinum A toxin treatment for blepharospasm and Meige syndrome: report of 100 patients.

One hundred patients (9.09 per cent) with blepharospasm from a grand total of 1,100 patients (at the Movement Disorders Clinic at Siriraj Hospital) who had been treated with botulinum A toxin (BTX-A) injection between 1989 and 1996 were analysed. The 100 patients comprised 65 females and 35 males with a female to male ratio of 1.86:1. Their mean age was 53.3 years (S.D. 12.03). Sixty patients had idiopathic blepharospasm, 31 patients were diagnosed with Meige syndrome (blepharospasm plus oromandibular dystonia) and nine patients with segmental dystonia (Meige syndrome plus cervical dystonia). The mean duration of suffering was 39.22 months (S.D. 44.83). Each patient received 30-50 IU of BTX-A injections according to the standard Siriraj injection pattern. Nine patients were lost to follow-up. The results of BTX-A injection were classified as: excellent result (an improvement of more than 75 per cent) in 83.51 per cent; a good response (an improvement of 50-75 per cent) in 13.19 per cent; a moderate response (an improvement of 25-50 per cent) in 2.20 per cent; and minimal or no response in 1.10 per cent. The complications of BTX-A injection were transient minimal ptosis (9.89 per cent), transient double vision (1.10 per cent) and excessive lacrimation (1.10 per cent). The efficacy of BTX-A injection lasted one to two months in 1.10 per cent, two to three months in 23.08 per cent, three to four months in 45.05 per cent, four to five months in 16.48 per cent, five to six months in 4.40 per cent and more than six months in 9.89 per cent. Botulinum A toxin injection is a simple and effective out-patient treatment for patients with blepharospasm, causing no systemic side-effects and minor transient local complications. The only drawback of this treatment is its high cost (100 IU cost 300 US dollars).

Dementia in Thai patients with Parkinson's disease: analysis of 132 patients.

A cross-sectional design study was done at Siriraj Hospital from 1990 to 1994 to determine the prevalence of dementia in Thai patients with Parkinson's disease. There were 81 males and 51 females with a male to female sex ratio of 1.59:1. One hundred and thirty two patients with Parkinson's disease were enrolled in this study. The mean duration of illness was 3.5 (S.D. 3.53) years. All patients were screened for depression by using the Thai Geriatric Depression Scale and patients with Alzheimer's disease or stroke were excluded from the study. The Thai Mental State Examination (TMSE) is a standard test used in this study to identify dementia in Thai patients with Parkinson's disease. Thirty four patients (25.76 per cent) scored TMSE below 23 points (cut-off point for dementia) and were considered as having dementia. Twenty four patients (18.18 per cent) scored below 20 points and were considered as having severe dementia, 12 patients (9.09 per cent) scored between 20-22 points (classified as mild to moderate dementia). Thirty seven patients (28.03 per cent) were in the borderline group as they had TMSE scores between 23-25 points. Fifty nine patients (44.70 per cent) were determined as nondemented as their TMSE scores were over 25 points. The items of cognitive function tests in TMSE which were severely impaired in the demented group were recall, attention and calculation whereas registration was relatively unaffected. Orientation and language were moderately impaired in the demented group. Dementia in Thai patients with Parkinson's disease is a significant problem for long term care of patients because of its high prevalence (one-fourth of all patients) and nearly one-fifth had severe dementia. Prompt recognition and proper management of dementia are required for family members and medical personnel to handle patients with Parkinson's disease.

An open label trial of pergolide in Thai patients with Parkinson's disease.

Fifteen Thai patients with Parkinson's disease (7 females, 8 males) were enrolled in an open label trial of pergolide (a new dopamine agonist) to evaluate its safety and efficacy. Inpatients and outpatients from Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand from 1992 to 1994 were included in the study with a total duration of 18 weeks. Both de novo patients and patients who were being treated with levodopa without dopamine agonist and were obtaining a less than optimal response at both visit 1 and visit 2 were all enrolled in this study. At entry into the study, 3 patients had Hoehn and Yahr stage I, 7 patients at stage II, 3 patients at stage III, and 2 patients at stage IV. Pergolide dosage was gradually built up until an optimal dosage was achieved. The average dose of pergolide during the study was 0.94 mg/day (range 0.075 to 8 mg/day). All patients completed the study and no patients dropped out. Two patients (13.33 per cent) experienced nausea (on 0.4 mg/day and 0.075 mg/day), two patients (13.33 per cent) experienced sleepiness (0.50 mg/day and 0.075 mg/day) and one patient (6.67 per cent) unsteadiness on walking (0.50 mg/day). There was one patient who required pergolide up to 8 mg/day which is higher than the recommended dosage (5 mg/day) but this patient experienced no adverse effects and his disabled dyskinesic was abolished. Our study demonstrated the good toleration and efficacy of pergolide treatment for Thai patients with Parkinson's disease. This new dopamine agonist stimulates both D1 and D2 receptors in comparison to other dopamine agonists (bromocriptine and lisuride) which stimulate only D2 receptors.

Dementia in Thai stroke survivors: analysis of 212 patients.

A cross-sectional designed study was done at Siriraj Hospital from 1990 to 1994 to determine the prevalence of dementia in Thai stroke survivors. Two hundred and twelve Thai stroke (both hemorrhage and infarction) survivors (132 males and 80 females) were enrolled in this study. The mean age of the study group was 62.78 (S.D. 11.12) years with the mean duration of stroke suffering of 2.09 (S.D. 2.74) years. All patients were screened for depression by using Thai Geriatric Depression Scale and patients with Alzheimer disease were excluded from the study. The Thai Mental State Examination (TMSE) is a standard test used in this study to identify stroke patients with dementia. Seventy stroke patients (33.02 per cent) scored below 23 points (cut-off point for dementia) and considered as dementia. Forty patients (18.88 per cent) scored below 20 points and were considered as having severe dementia, 30 patients (14.15 per cent) scored between 20-22 points (classified as mild to moderate dementia). Fifty-eight patients (27.36 per cent) were in the borderline group as they had TMSE scores between 23-25 points. Eighty four patients (39.62 per cent) of stroke survivors were determined as nondemented as their TMSE scores were over 25 points. The items of cognitive function tests in TMSE which were severely impaired in demented group were recall and calculation whereas registration and attention were relatively unaffected. Orientation and language were moderately impaired in the demented group.(ABSTRACT TRUNCATED AT 250 WORDS)

Diencephalic epilepsy resembling pheochromocytoma: a first reported case in Thailand.

A 31 year old hypertensive patient suffered from a fluctuation of blood pressure. Pheochromocytoma was suspected because of the clinical history, and extremely labile blood pressure but did not respond to therapy with alpha adrenergic blocking agent and normal excretion rates of catecholamine and vanilly mandelic acid (VMA). An enlarged left adrenal gland from computerized tomographic scan was found. So left adrenalectomy was performed and the result was consistent with cortical adrenal hyperplasia. Fluctuation of blood pressure still occurred after surgery with the symptoms of epigastric oppression and focal epileptic attack of the left arm. Epileptic potential waves were seen during hyperventilation from electroencephalogram but showed normal magnetic resonance imaging computerized tomographic scan of the brain. Diencephalic epilepsy was diagnosed and treated with anticonvulsant (carbamazepine) and eventually all of the symptoms including labile blood pressure subsided.

CSF finding in AIDS patients: Report of 112 cases.

One hundred and twelve cerebrospinal fluids from acquired immunodeficiency syndrome (AIDS) patients were analysed at Department of Neurology, Faculty of Medicine, Siriraj Hospital, Mahidol University during 1900-1993.The increasing rate rising from 3 (0.28%) cases to 12 (1.19%) cases, 33 (3.4%), 64 (7.4%) cases in 1990, 1991 1992 and 1993 respectively. The India ink preparation and latex agglutination revealed that 62 cases (-55%) of these patients had been infected with cryptococcus neoformans. Fach year the infection of this fungus in AIDS patients were increasing from 1 (33%) cases in 1990 to 5 (41%) cases in 1991, 20 (61%) case in 1992 and 36 (56%)cases in 1993. The mean value of white cell count, protein, and sugar of the AIDS patients infected with cryptococcus neoformans. were 39.43 cell/cumm (SD = 76.23), 77.91 mg/dl (SD = 62.91) and 35.46 mg/dl (SD = 19.48) respectively. These compositions were statistically significant lower than the AIDS patients that have the other complications. This study indicated that the AIDS patients have the low immune response to cryptococcus neoformans which is the major caused of the central nervous system disease in AIDS patients in Thailand.

A high incidence of neurological complications following Semple anti-rabies vaccine.

A study was conducted to determine the incidence of neurological complications among a cohort of 6,980 recipients of Semple vaccine administered in Bangkok and 5 nearby provinces in 1984. A review of all patients admitted to public hospitals in these 6 provinces discovered a total of 32 cases, with neurological complications following Semple vaccine. Twenty-two cases (68.8%) were encephalitis or myelitis. The complication rate was 3.6 times higher for males than females and the rate was lowest in the 0-14 year age group. Vaccinees receiving large daily dose of vaccine had a higher rate of complications than those with low dose regimen. One patient died, giving the case-fatality rate of 3.13 per cent. Since the search was limited, the rate of neurological complications to Semple vaccine was a minimum of 4.6 cases per 1,000 vaccinees [1:220]. This complication rate was much higher than most rates reported previously. It is imperative to find economically feasible alternatives to Semple vaccine.