Relationship between Insomnia and Depression in Type 2 Diabetics / 정신신체의학

OBJECTIVES: Many of the patients with type 2 diabetes are associated with sleep problems, and the rate of insomnia is known to be higher in the general population. The aims of this study were to know the frequency and clnical characteristics of insomnia, and related variables to insomnia in patients diagnosed with type 2 diabetes. METHODS: For 99 patients from 18 to 80 years of age (65 males and 34 females) with type 2 diabetes, interviews were performed. Total sleep time and sleep latency was evaluated. Insomnia was evaluated using the Korean Version of the Insomnia Severity Index (ISI-K). Severity of depressive symptoms were evaluted using the Korean version of the Hamilton Depression Scale (K-HDRM). According to the cutoff score of 15.5 on the ISI-K, subjects were divided into the group of type 2 diabetics with insomnia (N=34) and those without insomnia (N=65) at first, and then statistically analyzed. RESULTS: TInsomnia could be found in 34.34% of type 2 diabetics. Type 2 diabetics with insomnia had significantly more single or divorced (respectively 11.8%, p<0.05), higher total scores of the K-HDRS (11.76±5.52, p<0.001), shorter total sleep time (5.35±2.00 hours, p<0.001), and longer sleep latency (50.29±33.80 minutes, p<0.001). The all item scores of the ISI-K in type 2 diabetics with insomnia were significantly higher than those in type 2 diabetics without insomnia, that is, total (18.38±2.69), A1 (Initial insomnia) (2.97±0.76), A2 (Middle insomnia) (3.06±0.69), A3 (Terminal insomnia) (2.76±0.61), B (Satisfaction) (3.18±0.72), C (Interference) (2.09±0.97), D (Noticeability) (2.12±1.09) and E (Distress) (2.21±0.81) (respectively p<0.001). Variables associated with insomnia in type 2 diabetics were as following. Age had significant negative correlation with A3 items of the ISI-K (β=−0.241, p<0.05). Total scores of the K-HDRS had significant positive correlation, while total sleep time had significant negative correlation with all items of the ISI-K (respectively p<0.05). Sleep latency had significant positive correlation with total,, A1, B and E item scores of the ISI-K (respectively p<0.05). CONCLUSIONS: Insomnia was found in about 1/3 of type 2 diabetics. According to the presence of insomnia, clinical characteristics including sleep quality as well as quantity seemed to be different. Because depression seemed to be correlated with insomnia, clinicians should pay attention to early detection and intervention of depression among type 2 diabetics

Factors Influencing on the Cognitive Function in Type 2 Diabetics / 정신신체의학

OBJECTIVES: The aims of this study were to know the frequency and the nature of cognitive dysfunction in type 2 diabetics, and to reveal influencing variables on it. METHODS: From eighty type 2 diabetics (42 males and 38 females), demographic and clinical data were obtained by structured interviews. Cognitive functions were measured using the MMSE-K (Korean Version of the Mini-Mental State Examination) and the Korean Version of the Montreal Cognitive Assessment (MoCA-K) tests. Severity of depression was evaluated by the Korean Version of the Hamilton Depression Rating Scale (K-HDRS). RESULTS: 1) Among eighty type 2 diabetics, 13.75% were below 24 on the MMSE-K, while 38.8% were below 22 on the MoCA-K. 2) The total scores and subtest scores of the MoCA-K including visuospatial/executive, attention, language, delayed recall and orientation were significantly lower in type 2 diabetics with cognitive dysfunction (N=31) than those without cognitive dysfunction (N=49) (p < 0.001, respectively). 3) There were significant difference between type 2 diabetics with and those without cognitive dysfunction in age, education, economic status, body mass index, duration of diabetes, total scores of the K-HDRS, the MMSE-K and the MoCA-K (p < 0.05, respectively). 4) The total scores of the MoCA-K had significant correlation with age, education, body mass index, family history of diabetes, duration of diabetes, total scores of the K-HDRS (p < 0.05, respectively). 5) The risks of cognitive dysfunction in type 2 diabetics were significantly influenced by sex, education, fasting plasma glucose and depression. CONCLUSIONS: The cognitive dysfunction in type 2 diabetics seemed to be related to multiple factors. Therefore, more comprehensive biopsychosocial approaches needed for diagnosis and management of type 2 diabetes.

Association of Cognitive Dysfunction with Thyroid Autoantibody / 정신신체의학

OBJECTIVES: The aims of this study were to know the frequency of cognitive dysfunction among patients with autoimmune thyroid disorders, and to reveal influencing factors on it, especially to clarify association with autoimmune thyroid antibodies. METHODS: From sixty-five female patients with autoimmune thyroid disorders, demographic data were obtained by structured interview. Their cognitive funtions were measured using the MMSE-K and the MoCA-K tests. Depression was evaluated by the K-HDRS. RESULTS: 1) Among patients with autoimmune thyroid disorders, 7.69% of them were below 24 on the MMSE-K, while 10.77% were below 22 on the MoCA-K. The frequency of cognitive deficit was not significantly different according to having positivity to antimicrosomal antibodies or not. 2) The antimicrosomal antibody-positive patients had significantly higher antithyroglobulin antibody titers, antimicrosomal antibody titers, and TSH concentration, while had significantly lower free T4 levels(p<0.05, respectively). 3) The total scores of the MMSE-K and the MoCA-K had significant correlation with age, marital status, antithyroglobulin antibody titers and K-HDRS(p<0.05, respectively). 4) The regression analysis revealed that variables such as age, education, autoimmune thyroid antibodies, thyroid function and depression did not influence on cognitive function of patients with autoimmune thyroid disorders. CONCLUSIONS: Our results could not support that cognitive function of patients with autoimmune thyroid disorders had correlation with autoimmune thyroid antibodies.

Characteristics of Psychiatric Consultation between Presenile and Senile Inpatients / 정신신체의학

OBJECTIVES: The aim of this study was to know differences of characteristics between presenile and senile patients who were consulted to the department of psychiatry during medical-surgical admission. METHODS: The demographic and clinical data obtained from the medical records of psychiatric consultation in the presenile inpatients with age 50 to 64 years(N=162) and those of the senile inpatients with age over 65 years(N=171) were reviewed and compared. RESULTS: 1) The most common chief complaints for psychiatric consultation in presenile patients were somatic symptoms, anxiety and sleep disturbance in order, while cognitive decline, clouded consciousness and depressed mood were most common in senile patients with statistical significance. 2) The most frequent psychiatric diagnoses after consultation in presenile patients were delirium, mood disorder and substance use disorder in order, while delirium, mood disorder and major neurocognitive disorder were most frequent in senile patients with statistical significance. 3) There were no significant difference in numbers of physical illnesses, while numbers of therapeutic drugs for them were more in senile patients. CONCLUSIONS: Our study found significant differences between presenile and senile patients on psychiatric symptoms and diagnoses in geropsychiatric consultation. Therefore, more subdivided age-specific approach seems to be needed for the geropsychiatric consultation activities.

Change of Psychological Characteristics after Joining the Army According to Internet Addiction Tendency in Young Male Army Recruits

OBJECTIVES: The aim of this study was to find out the psychological changes associated with internet addiction between before and after the military drill among the young male army recruits. METHODS: All 1091 participants were army recruits aged from 19 to 22 years who participated in the 5-week military drill. They were assessed with some self-reported questionnaires [Sociodemographic questionnaires, Young's Internet Addiction Scale (IAS), the State-Trait Anxiety Inventory (STAI), the Beck Depression Inventory (BDI), the Barratt Impulsiveness Scale (BIS), the Attention-Deficit/Hyperactivity Disorder Self-Rated Scale (ASRS)]. They were divided into two groups, One is the internet addiction tendency group and the other is non-addiction group according to the IAS score. And the severity of the internet addiction tendency, depression, anxiety and impulsiveness were evaluated by the IAS, the STAI, the BDI, the BIS, the ASRS before and after military drill. RESULTS: The result of the paired t-test shows that the IAS, the STAI, the BDI, the BIS, the ASRS scores decreased after military drill in both non-addiction group and internet addiction tendency group. The result of the repeated measures ANOVA shows that there is an interaction effect between the changes of ASRS-hyperactivity (F = 23.437, p < 0.001), ASRS-impulsiveness (F = 4.896, p = 0.027), BIS-total (F = 4.057, p = 0.044), BIS-motor impulsiveness (F = 13.609, p < 0.001) scores and groups. The result of the generalized estimating equation shows that internet addiction tendency is associated with ASRS-inattention (beta = 0.075, p < 0.001), ASRS-hyperactivity (beta = 0.092, p = 0.002), STAI-trait anxiety (beta = 0.046, p < 0.001), BIS-motor impulsiveness (beta = 0.119, p = 0.028). CONCLUSIONS: The results show that psychopathologies such as internet addiction tendency, depression, anxiety, impulsiveness may improve after military drill regardless of the groups. Internet addiction tendency may be related to the ASRS-inattention, ASRS-hyperactivity, STAI-trait anxiety, motor-impulsiveness. So these findings may be considered in the treatment of internet addiction in terms of the impulsiveness control.

A Normative Study of Lexical Verbal Fluency in an Educationally-Diverse Elderly Population

OBJECTIVE: Lexical fluency tests are frequently used to assess language and executive function in clinical practice. We investigated the influences of age, gender, and education on lexical verbal fluency in an educationally-diverse, elderly Korean population and provided its' normative information. METHODS: We administered the lexical verbal fluency test (LVFT) to 1676 community-dwelling, cognitively normal subjects aged 60 years or over. RESULTS: In a stepwise linear regression analysis, education (B=0.40, SE=0.02, standardized B=0.506) and age (B=-0.10, SE=0.01, standardized B=-0.15) had significant effects on LVFT scores (p0.05). Education explained 28.5% of the total variance in LVFT scores, which was much larger than the variance explained by age (5.42%). Accordingly, we presented normative data of the LVFT stratified by age (60-69, 70-74, 75-79, and > or =80 years) and education (0-3, 4-6, 7-9, 10-12, and > or =13 years). CONCLUSION: The LVFT norms should provide clinically useful data for evaluating elderly people and help improve the interpretation of verbal fluency tasks and allow for greater diagnostic accuracy.

Cognitive Function of Thyroid Papillary Carcinoma Patients Before Radioiodine Therapy / 정신신체의학

OBJECTIVES: The aims of this study were to know the prevalence of cognitive disorders in patients with thyroid cancer, and identify related variables to them. METHODS: Subjects were consisted of fourty-two patients with thyroid cancer, who were admitted for radioiodine ablative therapy at 6-12 months after total thyroidectomy. The data were obtained from interviews about history and assessments of depression and cognitive function(Korean Version of the Montreal Cognitive Assessment, MoCA-K). RESULTS: 1) Among subjects, those with below 22 of total score of the MoCA-K were twenty-one(50.0%). 2) Upon age, education, Pre-radioiodine therapy thyroid stimulating hormone(TSH), there were statistically significant difference between subgroup with above 23 of the total MoCA-K score and those below 22. 3) The total scores of the MoCA-K in subjects had significant correlation with age, education, comorbidity, Pre-radioiodine therapy TSH, total score of the HDRS-17. CONCLUSIONS: Cognitive disorders were more prevalent among patients with thyroid cancer before radioiodine therapy. Therefore, further study should be needed to clarify the mechanism for the cognitive disorders in thyroid cancer. Furthermore, physicians should pay attention to the cognitive function and prepare preventative measures for cognitive disorder during management of thyroid cancer.

Outline of psychiatric disorders of the elderly

Psychiatric disorders of the elderly are significantly increasing in importance. Moreover, Korea is transitioning more rapidly to an aged society than any other country in the world. Psychiatric disorders of the elderly include typical dementia, depression, anxiety, late-life psychosis, and sleep disorders. Patients also may need to see a geriatric psychiatrist for chronic pain, Parkinson's disease, heart disease, diabetes, stroke, or other medical disorders. Older adults have special physical, emotional, and social needs. The principle therapeutic guidelines for elderly psychiatric disorders are based on comprehensive diagnosis and treatment including co-existing medical illnesses and medications, family, social and environmental issues. An integrated paradigm for prevention, diagnosis, rehabilitation, and multidisciplinary approaches are essential. We reviewed the literature on the background, classification, diagnosis, and treatment of psychiatric disorders of the elderly. Treatment was classified into pharmacological and non-pharmacological intervention. Psychiatric disorders of the elderly covers from brain to community based on being able to treat elderly disorders successfully and improving quality of life.

Comparison of the Validity of Screening Tests for Dementia and Mild Cognitive Impairment of the Elderly in a Community : K-MMSE, MMSE-K, MMSE-KC, and K-HDS / 신경정신의학

OBJECTIVES : The authors have evaluated the validity of four currently used screening tools of cognitive function in Korea for dementia and mild cognitive impairment in a community elderly population. METHODS : We screened 5,085 non-randomly sampled elderly over age 60 in the Gwangju city, Gyeonggi Province. Among those, 927 persons were examined further for evidence of dementia and mild cognitive impairment (MCI). A baseline questionnaire on sociodemographic characteristics and four major screening tests (K-MMSE, MMSE-K, MMSE-KC, and K-HDS) were administered. For the evaluation of validity, we have analyzed the ROC curve and calculated the sensitivity and specificity of each test at its optimal cutoff points. RESULTS : ROC analysis of the 3 MMSEs and K-HDS has shown that area under the curve (AUC) was between 0.897 and 0.923 for dementia. Sensitivity and specificity were 0.768 and 0.870, respectively, when the cutoff line was set at 17/18 in K-MMSE. The other two MMSEs had optimal cutoff lines at 16/17 with sensitivity of 0.768 and specificity more than 0.90. K-HDS had its optimal cutoff line at 18/19 with higher sensitivity (0.874) and lower specificity (0.755). Compared with dementia, the four screening tests showed poor validity on MCI. Sensitivity and specificity was in the range of 0.733-0.756 and 0.840-0.855, respectively. CONCLUSION : The validity of the screening tools which are currently being used in Korea to screen for MCI was not significantly different among tests. Because of the difference in the population norm and z-score estimation, use of the common norm is advisable.

Diagnosis and Treatment for Behavioral and Psychological Symptoms of Dementia

Dementia is a common neuropsychiatric disorder characterized by progressive impairment of cognitive abilities and distinct behavioral and psychological symptoms. In particular, various behavioral and psychological symptoms of dementia (BPSD) add to the burden of family and society. Moreover, the number of dementia patients is rapidly growing with increasing elderly population. The main symptoms of BPSD are anxiety, depression, delusions and hallucinations. BPSD produce significant problems for both patients and caregivers. Aggravated BPSD accelerates impairment of cognitive function and induces early nursing home placement, increasing cost for care while decreasing quality of life. The pathophysiology of BPSD is determined by genetic, structural, or environmental factors. Diagnosis of BPSD used "NPI, BEHAVE-AD and BRSD of CERAD". The management of BPSD requires both pharmacological and non-pharmacological treatment. When BPSD are mild, non-pharmacological strategies are essential, but for patients with moderate to severe BPSD, pharmacological intervention should also be emphasized.

Inappropriate Prescribing in the Elderly Patients

In older people, medicines are considered appropriate when they have an evidence-based indication, are well-tolerated and cost-effective. However, inappropriate prescribing (IP) is a common and significant healthcare problem in elderly people in Korea as well as in the world. IP in old people is highly prevalent but preventable. Screening for IP is highly desirable, since detection and correction are simple and worthwhile. Until now, Beers' criteria for IP dominate the international literatures, although they have some defects. The 2002 version of Beers' criteriaindependent of diagnosis includes 48 different categories of either single medications or multiple medications of a similar class identified as IP, and the 2002 version of Beers' criteria-considering diagnosis contains 19 different categories containing possible drug-disease interaction. Successful approaches to optimizing prescribing have been either educational or administrative. More research specially focused on the IP in the elderly is needed.

Relationship Between Subjective Memory Complaints and Cognition in the Elderly

OBJECTIVES: We aimed to investigate the relationship between subjective memory complaints and cognition in the elderly. METHODS: Data obtained from 1,496 subjects (510 men and 986 women) aged above 60 years was analyzed from the Gwangju Dementia and Mild Cognitive Impairment Study (GDEMCIS). All subjects completed the study questionnaire including demographic characteristics, history of current and past illnesses, drug history, Korean version-Mini Mental State Examination (K-MMSE), and Short Form Korean version of Geriatric depression scale (SGDS-K). Subjective memory complaints were defined in two different ways; worse than others (SMC-O) and worse than one's past (SMC-P). RESULTS: On analysis of covariance, there was significant difference of estimated marginal means of K-MMSE score among five SMC-P groups (much improve:18.0, little improve:21.3, not changed:21.2, little worse:21.1, much worse:20.2) after adjusting age, sex, educational level and depression (F=9.63, df=4, p<0.0001, adjusted R2=0.375). There was significant difference of estimated marginal means of K-MMSE score among three SMC-O groups (below peer's average:20.4, peer's average:20.9, above peer's average:21.8) after adjusting age, sex, educational level and depression (F=4.89, df=2, p=0.043, adjusted R2=0.0.361). CONCLUSION: These results suggest that subjective memory complaints may be an indicator of objective cognitive impairment in the elderly.

Correlation between Head Circumference and Cognition in the Elderly by ApoE Genotype / 신경정신의학

OBJECTIVES: The aim of this study is to find out the effect of ApoE genotype on correlation between head circumference and cognition of the elderly in the community. METHODS: A total of 1,152 subjects (380 men and 772 women) aged 60-91 years were analyzed from preliminary data of GDEMCIS (Gwangju Dementia and MCI Study). The study questionnaire consisted of demographic characteristics, current and past illness history, drug history and K-MMSE (Korean version-Mini Mental State Examination). We also measured the head circumference and examined ApoE genotype. RESULTS: On regression analysis, as head circumference becomes smaller, K-MMSE scores decreased adjusted by age, sex, educational level, ApoE epsilon4 allele, current smoking and alcohol drinking status (beta=0.15, p=0.04). Only in the lowest quartile group, presence of ApoE epsilon4 allele reduced K-MMSE scores adjusted by age, sex, educational level, height, current alcohol drinking and smoking status (beta=-1.39, p=0.008). CONCLUSION: These results suggest that head circumference may have an influence on K-MMSE scores, and presence of ApoE epsilon4 allele may be a medicating factor.

Correlation between Head Circumference and Visuospatial Ability of Elderly in Community

OBJECTIVES: The aim of this study is to find out the correlation between head circumference and visuospatial function of the elderly in community. METHODS: A total of 463 subjects (170 men and 293 women) aged 60-91 years were analyzed from preliminary data of GDEMCIS (Gwangju Dementia and MCI Study). The study questionnaire consisted of demographic characteristics, current and past illness history, drug history, K-MMSE, SNSB-D. We also measured head circumference and examined ApoE genotype. RESULTS: On regression analysis, as head circumference become smaller, visuospatial memory scores (S-Rey immediate recall & delayed recall) decreased adjusted by age, height, sex, educational level, ApoE epsilon 4 allele, current smoking and alcohol drinking (beta=0.18, p=0.002, beta=0.15, p=0.01). Presence of ApoE epsilon 4 allele has no direct correlation with head circumference and cognitive decline. CONCLSION: As head circumference become smaller, only visuospatial memory scores decreased significantly. These results suggest that visuospatial memory function might be one of the sensitive markers of brain reserve differences.

Correlation between Metabolic Syndrome and Cognition in the Elderly / 신경정신의학

OBJECTIVE: The purpose of this study is to find out the effect of ApoE genotype in correlation between metabolic syndrome and cognition of the elderly in the community. METHODS: A total of 1,305 subjects (440 men and 865 women) aged 60-98 years were analyzed from preliminary data of Gwangju Dementia and MCI Study (GDEMCIS). The metabolic syndrome was assessed as defined by the modified National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III). The study questionnaire consisted of demographic characteristics, current and past illness history, drug history, family history of dementia and stroke, and Korean version-Mini Mental State Examination (K-MMSE). We also examined ApoE genotype and analyzed associated factors with metabolic syndrome. RESULTS: These Metabolic syndrome was present in 28.6% of the subjects (13.4% of men and 36.3% of women). On multiple logistic regression analysis, low serum HDL cholesterol was associated with an increased risk for cognitive impairment (K-MMSE score < or = 17) adjusted by age, sex, educational level, and smoking in the presence of ApoE epsilon4 allele (OR 0.95, 95% CI 0.92-0.99). CONCLUSION: These results suggest that serum HDL cholesterol may affect cognitive function in the elderly in the presence of ApoE epsilon4 allele.

Effect of ApoE Genotype on the Relationship between Nutritional Risk and Cognition in the Elderly

BACKGROUND: The purpose of this study is to find out the effect of ApoE genotype on the relationship between nutritional risk and cognition of the elderly in a community. METHODS: A total of 996 subjects (343 men and 653 women) aged 60~91 years were analyzed from preliminary data of GDEMCIS (Gwangju Dementia and MCI Study). The study questionnaire consisted of demographic characteristics, current and past illness history, drug history, K-SGDS (Korean version of Short Form Geriatric Depression Scale), K-MMSE (Korean version-Mini Mental State Examina- tion), and NSI (Nutritional Screening Initiative) checklist. We also examined blood pressure, fasting serum glucose, lipid profile, body mass index, and ApoE genotyping. RESULTS: 649 subjects (65.2%) were on good nutritional state (NSI score or = 3). On multiple logistic regression analysis, moderate or high nutritional risk was associated with an increa- sed risk for cognitive impairment (K-MMSE score < or = 17) after adjustment with age, sex, K-GDS and educational level in the absence of ApoE epsilon4 allele (OR 1.78, 95% CI 1.15-2.77). CONCLUSION: These results suggest that nutritional risk may be associated with cognitive function in the elderly only in the absence of ApoE epsilon4 allele.

Analysis of Current Status of Management for Dementia between City and Country Health Center

OBJECTIVES: The purpose of this study was as follows: 1) to compare the current status of management for dementia between city and country health center. 2) to check the amount and detailed items of budgets for dementia in dementia counseling center, referral courses for registration of dementia patient, number of dementia patient referred to welfare institutions for the elderly. 3) to understand the troubles in management for dementia in health center and to provide baseline data about future community dementia management system. METHOD: The questionnaire was administered to 248 public health centers. The 162 collected questionnaires were used in analysis and the whole response rate was 65.3%. Questionnaire composed by general contents about dementia management in health center and dementia counseling center. Statistical analysis was conducted to compare the difference about each item in city and country health center. RESULTS: City and country health center showed differences in number of registered dementia patient, budgets for dementia, referral courses for registration of dementia patient, number of dementia patient referred to institution, troubles in management for dementia in health center. CONCLUSION: Current dementia management system does not meet the various needs of community for management of dementia. Thus, complementary strategies are needed to solve this problem.

Clinical Approaches to the Long-term Care Service focused on Dementia

The long-term care(LTC) service for frail elderly persons is one of the most challenging issues throughout the world. The public provision of LTC in Korea is still in its infancy. The main policy concerning LTC should include qualitative aspects such as autonomy, privacy, and consumers' right of elderly persons. Dementia is a brain disorder characterized by acquired loses of cognitive, emotional and functional abilities. Dementia has emerged as a major morbidity not only to health care providers and the families but also to the social health policy. The dementia service system has been developed as a national policy model such as the ten-year plan of dementia (1996~2005), and the LTC system has been mainly focused on institutionalization. Although chronic facilities such as large nursing homes for the service for dementia can relieve the economic burden, the dementia service needs a community-based, comprehensive care system encompassing early detection and diagnosis of dementia.

Four Years Reviewer Evaluation Reports of "Journal of Korean Neuropsychiatric Association" / 신경정신의학

Four Years Reports of "Journal of Korean Neuropsychiatric Association" during 2001 to 2005 were evaluated by 18 Editorial Board of Korean Neuropsychiatric Association. We investigated the articles to specific fields and rejection rate etc. by different section chiefs. Although several problems concerning review time duration and rejection guideline issues indicated but generally all reviewer processes proved relatively clear and concise criteria. Through these objective and systematic evaluation processes, "Journal of Korean Neuropsychiatric Association" will develop a good journal.

Four Years Reviewer Evaluation Reports of "Journal of Korean Neuropsychiatric Association" / 신경정신의학

Four Years Reports of "Journal of Korean Neuropsychiatric Association" during 2001 to 2005 were evaluated by 18 Editorial Board of Korean Neuropsychiatric Association. We investigated the articles to specific fields and rejection rate etc. by different section chiefs. Although several problems concerning review time duration and rejection guideline issues indicated but generally all reviewer processes proved relatively clear and concise criteria. Through these objective and systematic evaluation processes, "Journal of Korean Neuropsychiatric Association" will develop a good journal.