Development and validation of the Ascertain Dementia 8 (AD8) Thai version.

BACKGROUND: The Ascertain Dementia 8 (AD8) is a brief informant-based questionnaire which reliably distinguishes patients with neurocognitive disorder (NCD) and normal cognition. Our objective was to translate the AD8 into Thai and test its validity as a potentially useful measure to detect patients with the mild stage of major NCD due to Alzheimer disease (major NCD-AD). METHODS: Evaluations of 144 informant-patient dyads were made. Participants were patients who attended the memory clinic at Ramathibodi Hospital and non-patient volunteers. The AD8-Thai version was administered separately from doctor's interviews and neuropsychological assessments. Diagnostic workups included a complete medical history, physical and neurological examinations, neuropsychological testing, the Clinical Dementia Rating Scale-Sum of Boxes (CDR-SOB), Montreal Cognitive Assessment (MoCA), blood tests and brain imaging, preferably with magnetic resonance imaging. All researchers were blinded to the AD8 results. RESULTS: An AD8 score ≥3 had a sensitivity of 95.5%, a specificity of 89.5%, a positive predictive value of 84%, and a negative predictive value of 97.1% for screening major NCD-AD and those with normal cognition. A subgroup analysis with participants aged ≥65 years and with ≥12 years of education revealed comparable ability to the whole group. AD8 scores had a moderate negative relationship with MoCA scores (r = -0.470) and a strong positive relationship with CDR-SOB scores (r = 0.547). The performance of AD8 scores in differentiating mild NCD from normal cognition was not as good as for major NCD-AD. CONCLUSIONS: AD8-Thai version is an acceptable screening tool for major NCD-AD. For patients aged 65 years or older, with at least 12 years of education, and with cognitive complaints in memory clinic, an AD8-Thai score of 3 or more would be sufficient to work on major NCD diagnosis. The performance of the AD8-Thai in mild NCD needs further investigation.

Rate of conversion from mild cognitive impairment to dementia in a Thai hospital-based population: A retrospective cohort.

Introduction: Mild cognitive impairment (MCI) is the state between normal cognition and dementia. This study objective was to estimate an average 1-year rate of conversion from MCI to dementia and explore the associated factors of conversion in a hospital-based cohort. Methods: A retrospective cohort study of participants with MCI was conducted in a tertiary care hospital in Thailand. Two hundred fifty participants, 50 years of age or older, were enrolled. Results: An average 1-year conversion rate from MCI to dementia was 18.4%. MCI patients who converted to dementia were likely older (P < .001), predominantly female (P = .028), vitamin D deficient (P = .012), and associated with lower Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores during first assessments (P < .001, P < .001 respectively) and follow-up assessments (P < .045, P < .001 respectively). We conducted two models of multivariate analysis, using binary logistic regression. In the first model, adjusted for age, sex, education, vitamin D deficiency, and first assessment MMSE scores, we found that underlying vitamin D deficiency (odds ratio [OR] = 3.13, 95% confidence interval [CI] 1.04 to 9.44) and first assessment MMSE scores (OR = 0.83, 95% CI 0.73 to 0.93) were significantly associated with conversion to dementia. In the second model, adjusted for age, sex, education, vitamin D deficiency and first assessment MoCA scores, only first assessment MoCA scores (OR = 0.58, 95% CI 0.45 to 0.76) were significantly associated with conversion to dementia. Discussion: The 1-year conversion rate from MCI to dementia was 18.4%. MMSE and MoCA were useful tools to assess baseline cognitive status in MCI patients and predict dementia progression. The association between vitamin D deficiency and risk of conversion from MCI to dementia requires further investigations.

Sleep quality problems in Thai medical students.

Objective: To explore sleep quality and daytime sleepiness problems in medical students at Ramathibodi Hospital. Methods: This was a cross-sectional study. Data were collected using questionnaires. The questionnaires included (1) Demographic and personal data, (2) The Pittsburgh Sleep Quality Index (PSQI) for sleep quality problem assessment and (3) The Epworth Sleepiness Scale (ESS) for daytime sleepiness assessment. Results: Of 691 medical students, 165 (23.9%) completed questionnaires. The prevalence of poor sleep quality and daytime sleepiness were 63.6% and 41.8%, respectively. After adjusted for age and relationship concern, academic concern (prevalence ratio 1.46) and nighttime activity without screen (prevalence ratio 1.43) were associated significantly with sleep quality problem. No factor was associated with daytime sleepiness. Discussion: Interventions to reduce academic burdens should be promoted to improve sleep problems in medical students. Further studies in larger groups of medical students using both subjective and objective measurements should be done in the future.

Drug treatment for panic disorder with or without agoraphobia: systematic review and network meta-analysis of randomised controlled trials.

OBJECTIVE: To identify drug classes and individual selective serotonin reuptake inhibitors (SSRIs) with high rates of remission and low risk of adverse events in the treatment of panic disorder with or without agoraphobia. DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Embase, Medline, and ClinicalTrials.gov from inception to 17 June 2021. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Randomised controlled trials that included adults aged ≥18 years with a diagnosis of panic disorder, compared drugs used to treat the panic disorder, and measured the outcomes of interest, including remissions, dropouts, and adverse events. METHODS: Risk of bias in the included studies was assessed using the revised Cochrane risk of bias tool for randomised trials. Direct meta-analyses were performed using random effects models. A two stage network meta-analysis with surface under the cumulative ranking curve (SUCRA) was used to estimate the comparative efficacy of drug classes and individual SSRIs. RESULTS: 87 studies including a total of 12 800 participants and 12 drug classes were eligible for inclusion. Almost all the studies (86/87) had some concern or were at high risk of bias. Network meta-analysis of remission with consistent results indicated that tricyclic antidepressants, benzodiazepines, monoamine oxidase inhibitors, SSRIs, and serotonin-noradrenaline reuptake inhibitors (SNRIs) were associated with significantly higher remission rates than placebo, with risk ratios of 1.39 (95% confidence interval 1.26 to 1.54), 1.47 (1.36 to 1.60), 1.30 (1.00 to 1.69), 1.38 (1.26 to 1.50), and 1.27 (1.12 to 1.45), respectively. SUCRAs identified benzodiazepines (84.5%, mean rank=2.4), tricyclic antidepressants (68.7%, 3.8), and SSRIs (66.4%, 4.0) as the top three best treatments for remission. However, tricyclic antidepressants, benzodiazepines, and SSRIs were also significantly associated with increased risk of adverse events compared with placebo, with risk ratios of 1.79 (1.47 to 2.19), 1.76 (1.50 to 2.06), and 1.19 (1.01 to 1.41), respectively. Consistency assumption of adverse events was upheld but could still be present on removal of studies with high percentages of women participants and those with agoraphobia. A SUCRA cluster ranking plot considering both remission and adverse events among all drug classes indicated that SSRIs were associated with high remission and low risk of adverse events. Among individual SSRIs, sertraline and escitalopram provided high remission with an acceptable risk of adverse events. CONCLUSION: The findings suggest that SSRIs provide high rates of remission with low risk of adverse events for the treatment of panic disorder. Among SSRIs, sertraline and escitalopram were associated with high remission and low risk of adverse events. The findings were, however, based on studies of moderate to very low certainty levels of evidence, mostly as a result of within study bias, inconsistency, and imprecision of the findings reported. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020180638.

Depressive disorders in Thai medical students: an exploratory study of institutional, cultural, and individual factors.

OBJECTIVES: This exploratory qualitative study conducted among Thai medical students aimed to investigate factors related to the development of medical students' depression and how these factors interact in contributing to depressive disorders. METHODS: Forty-three undergraduate medical students of the six-year Doctor of Medicine program were identified as having moderate to severe depression on an annual depression screening. From these, eighteen students agreed to participate in individual in-depth interviews. Transcriptions of the interviews were analyzed by independent reviewers using a thematic analysis approach. RESULTS: Among 43 participants screened as having moderate-to-severe depression, major depressive disorder and adjustment disorder were 9.3% and 14.0%, respectively. Reported factors related to medical students' disorders were personal vulnerabilities, medical educational administration, academic achievement, learning environment, intrinsic motivation, self-care and self-management, relationship, and community. In particular, lack of social support and relationship problems were mentioned among those with more severe and persistent symptoms. Protective factors were social support, positive relationships, a growth mindset, spiritual and mindfulness practices, and an adequate mentoring program. CONCLUSIONS: Medical students' depression and suicidal ideations are significant concerns in Thai medical education. Besides personal vulnerabilities, high expectations, the value placed on academic achievement, and relationship problems can precipitate the onset of depressive disorders, if not being properly addressed. The 4P framework of predisposing, precipitating, perpetuating, and protective factors are suggested to understand the onset and development of students' depressive disorders and to identify targets for institutional and educational intervention.

Development and validation of a screening instrument for cognitive fluctuation in patients with neurocognitive disorder with Lewy bodies (NCDLB): the Mayo Fluctuations Scale-Thai version.

BACKGROUND: Prevalence of neurocognitive disorder with Lewy bodies (NCDLB) is low in Asian populations, which may partially reflect its diagnostic difficulty. The Mayo Fluctuations Scale, a short questionnaire that evaluates cognitive fluctuation, has been shown to significantly differentiate NCDLB from Alzheimer's disease. AIM: This study aimed to develop the Mayo Fluctuations Scale-Thai version and assess its validity to screen NCDLB in an elderly population. METHODS: The Mayo Fluctuations Scale was translated into Thai. The process involved back-translation, cross-cultural adaptation, field testing of the prefinal version, as well as final adjustments. From all patients attending the Psychiatric and Memory Clinic at Ramathibodi Hospital, 135 patients accompanied by their primary caregivers were included. Caregivers were interviewed by research assistants using a four-item scale, and psychiatrists determined patients' diagnosis based on the diagnostic and statistical manual of mental disorders (DSM)-5 criteria. Evaluations performed by psychiatrists and research assistants were blinded. RESULTS: Seventeen participants had been diagnosed with major NCDLB. At a cut-off score of 2 or over, the Mayo Fluctuations Scale exhibited excellent performance to differentiate major NCDLB from other major neurocognitive disorders (NCDs), with a sensitivity of 94.1% and a specificity of 71.4%, and acceptable performance to differentiate mild NCDLB from other mild NCDs, with a sensitivity of 60% and a specificity of 93.1%. CONCLUSION: The Mayo Fluctuations Scale-Thai version is an excellent screening tool for major NCDLB and an acceptable tool that may be used with other additional tests for mild NCDLB. The tool is practical for use in memory and psychiatric clinics. Further validation studies in participants with other specific clinical conditions are required.

Application of the European quality indicators for psychosocial dementia care in long-term care facilities in the Asia-Pacific region: a pilot study.

OBJECTIVES: An Asia-Pacific regional collaboration group conducted its first multi-country research project to determine whether or not European quality indicators (QIs) for psychosocial care in dementia could be implemented as a valid tool in residential aged care across seven Asia-Pacific sites (Australia, Hong Kong Special Administrative Region, Mainland China, Malaysia, Singapore, South Korea, and Thailand). METHOD: Following the European QI protocol, auditing and data extraction of medical records of consenting residents with dementia were conducted by trained auditors with relevant health care backgrounds. Detailed field notes by the auditors were also obtained to describe the characteristics of the participating care facilities, as well as key issues and challenges encountered, for each of the 12 QIs. RESULTS: Sixteen residential care facilities in the seven Asia-Pacific sites participated in this study. Data from 275 residents' records revealed each of the 12 Qis' endorsement varied widely within and between the study sites (0%-100%). Quality of the medical records, family and cultural differences, definitions and scoring of certain indicators, and time-consuming nature of the QI administration were main concerns for implementation. CONCLUSION: Several items in the European QIs in the current format were deemed problematic when used to measure the quality of psychosocial care in the residential aged care settings in participating Asia-Pacific countries. We propose refinements of the European QIs for the Asian-Pacific context, taking into account multiple factors identified in this study. Our findings provide crucial insights for future research and implementation of psychosocial dementia care QIs in this region.

Cholinesterase Inhibitors and Behavioral & Psychological Symptoms of Alzheimer's Disease.

OBJECTIVE: Examine the effect of cholinesterase inhibitors (ChEIs) on behavioral and psychological symptoms of dementia (BPSD) in patients with Alzheimer's disease (AD), and compared the dosages of antipsychotics and SSRIs or SNRIs used to treat BPSD in patients with and without ChEIs. MATERIAL AND METHOD: The cross-sectional study of Alzheimer patients who had been taking ChEls for at least six months (ChEI+) or had never been on any ChEIs (ChEI-) were enrolled from the Memory Clinic, Ramathibodi hospital between September 1, 2014 and February 28, 2015. All of these patients were evaluated with Mini-Mental Status Exam (MMSE) for cognitive function, Neuropsychiatric Inventory-Questionnaire (NPI-Q) for BPSD, and psychotropic dosage used. RESULTS: Fifty-one Alzheimer patients were enrolled, 31 patients in the ChEI+ group and 20 patients in the ChEI- group. Mean and SD of MMSEs in ChEI+ and ChEI- were 13.6 ± 1.2 and 11.75 ± 1.4, respectively (p-value = 0.33). The Mean and SD of NPI scores in ChEI+ and ChEI- were 15.68 ± 14.31 and 19.5 ± 20.1, respectively (p-value = 0.43). Patients in ChEI + had tend to had a lower depression severity score (p = 0.10) and lower burden from aggression/agitation (p = 0.08). The differences were not statistically signifcant. Mean highest dosages per day (olanzapine equivalence) in the ChEI+ and ChEI- were 1.6 mg and 3.1 mg, respectively (p-value = 0.07). CONCLUSION: The total off NPI score between the ChEI+ and ChEI- groups were not different, but there were report the trends toward lower depression severity score, aggression/agitation distress score, and antipsychotic dosages use in the ChEI+.

Active versus receptive group music therapy for major depressive disorder-A pilot study.

OBJECTIVES: To compare the effects of 1) active group music therapy and 2) receptive group music therapy to group counseling in treatment of major depressive disorder (MDD). DESIGN & SETTING: On top of standard care, 14 MDD outpatients were randomly assigned to receive 1) active group music therapy (n=5), 2) receptive group music therapy (n=5), or 3) group counseling (n=4). There were 12 one-hour weekly group sessions in each arm. MAIN OUTCOME MEASURES: Participants were assessed at baseline, 1 month (after 4 sessions), 3 months (end of interventions), and 6 months. Primary outcomes were depressive scores measured by Montgomery-Åsberg Depression Rating Scale (MADRS) Thai version. Secondary outcomes were self-rated depression score and quality of life. RESULTS: At 1 month, 3 months, and 6 months, both therapy groups showed statistically non-significant reduction in MADRS Thai scores when compared with the control group (group counseling). The reduction was slightly greater in the active group than the receptive group. Although there were trend toward better outcomes on self-report depression and quality of life, the differences were not statistically significant. CONCLUSION: Group music therapy, either active or receptive, is an interesting adjunctive treatment option for outpatients with MDD. The receptive group may reach peak therapeutic effect faster, but the active group may have higher peak effect. Group music therapy deserves further comprehensive studies.

Psychiatric comorbidities in patients with major depressive disorder.

BACKGROUND: Psychiatric comorbidities are common in major depressive disorder (MDD). They may worsen outcome and cause economic burden. The primary objective was to examine the prevalence of psychiatric comorbidities in MDD. The secondary objectives were to compare the presence of comorbidities between currently active and past MDD, and between patients with and without suicidal risk. METHODS: This was a cross-sectional study. A total of 250 patients with lifetime MDD and age ≥18 years were enrolled. The Mini International Neuropsychiatric Interview (MINI), Thai version, was used to confirm MDD diagnosis and classify comorbidities. MDD diagnosis was confirmed in 190, and 60 patients were excluded due to diagnosis of bipolar disorder. RESULTS: Of the 190 MDD patients, 25.8% had current MDD and 74.2% had past MDD. Eighty percent were women. The mean age at enrollment was 50 years, and at MDD onset was 41 years. Most patients were married (53.2%), employed (54.8%), and had ≥12 years of education (66.9%). There were 67 patients (35.3%) with one or more psychiatric comorbidities. Comorbidities included dysthymia (19.5%), any anxiety disorders (21.1%) (panic disorder [6.8%], agoraphobia [5.8%], social phobia [3.7%], obsessive-compulsive disorder [OCD] [4.7%], generalized anxiety disorder [5.3%], and post-traumatic stress disorder [4.2%]), alcohol dependence (0.5%), psychotic disorder (1.6%), antisocial personality (1.1%), and eating disorders (0%). Compared with past MDD, the current MDD group had significantly higher OCD (P<0.001), psychotic disorder (P=0.048), past panic disorder (P=0.017), and suicidal risk (P<0.001). Suicidal risk was found in 32.1% of patients. Patients with suicidal risk had more comorbid anxiety disorder of any type (P=0.019) and psychotic disorder (P=0.032). CONCLUSION: Several comorbidities were associated with MDD. Patients with active MDD had higher comorbid OCD, psychotic disorder, past panic disorder, and suicidal risk. Patients with suicide risk had higher comorbid anxiety and psychotic disorders.

Capgras syndrome in Dementia with Lewy Bodies.

BACKGROUND: Capgras syndrome is characterized by the recurrent, transient belief that a person has been replaced by an identical imposter. We reviewed clinical characteristics of Dementia with Lewy Bodies (DLB) patients with Capgras syndrome compared to those without Capgras. METHODS: We identified 55 consecutive DLB patients (11 cases with Capgras syndrome (DLB-C) and 44 cases without evidence of Capgras (DLB). Semi-structured interviews with the patient and an informant, neurological exams, and neuropsychological testing were performed. Caregivers were assessed for caregiver burden and depression. Primary comparisons were made between DLB-C and DLB. Exploratory analyses using stepwise logistic regression and bootstrap analyses were performed to determine clinical features associated with Capgras. RESULTS: DLB-C patients experienced more visual hallucinations and self-reported anxiety, had higher scores on the Neuropsychiatric Inventory, and were less likely to be treated with cholinesterase inhibitors at time of initial evaluation. Extrapyramidal symptoms and depression were not associated with Capgras. Caregivers of DLB-C patients had higher caregiver burden. DLB-C was associated with self-reported anxiety (OR = 10.9; 95% CI = 2.6-47.6). In a bootstrap analysis, clinical findings that were predictors of Capgras included visual hallucinations (log(OR) = 18.3; 95% CI = 17.9-19.3) and anxiety (log(OR) = 2.9; 95% CI = 0.31-20.2). CONCLUSIONS: Our study suggests that Capgras syndrome is common in DLB and usually occurs in the presence of anxiety and visual hallucinations, suggesting related etiopathogenesis. Early appreciation of Capgras syndrome may afford the opportunity to alleviate caregiver burden and improve patient and caregiver outcomes.

Use of medical foods and nutritional approaches in the treatment of Alzheimer's disease.

Alzheimer's disease, the most common cause of dementia, has a high global economic impact. To date, there is no curative treatment; therefore, many efforts are directed not only at novel potential disease-modifying treatments and interventions, but also to develop alternative symptomatic and supportive treatments. Examples of these efforts include the medical foods. There are three medical foods that claim to offer symptomatic benefits: Axona(®), Souvenaid(®) and CerefolinNAC(®). Axona supplies ketone bodies as alternative energy source to neurons. Souvenaid provides precursors thought to enhance synaptic function. CerefolinNAC addresses the role of oxidative stress related to memory loss. The current scientific evidence on these medical foods is reviewed in this article. Furthermore, we also review the concept and evidence supporting use of the Mediterranean diet, a possible alternative to medical foods that, if implemented correctly, may have lower costs, fewer side effects and stronger epidemiological health outcomes.

Memantine ER, a once-daily formulation for the treatment of Alzheimer's disease.

IMPORTANCE OF THE FIELD: Alzheimer's disease is a progressive, degenerative brain disease. As the disease progresses, patients and caregivers face increasing problems with medication adherence. Given its relentlessly progressive nature, newer and more effective therapies for Alzheimer's disease are needed. Memantine 10 mg twice daily is the FDA-approved regimen for the treatment of moderate to severe Alzheimer's disease. AREAS COVERED IN THIS REVIEW: The goal of this article is to review the once-daily memantine ER 28 mg formulation for the treatment of Alzheimer's disease, which, by simplifying the dosage regimen, decreases the problems of medication adherence. A new extended-release formulation has been developed to improve adherence and possibly efficacy without compromising an excellent tolerability and safety profile. There is also a possibility of dose-dependent improvement/superiority in cognitive, global and behavioral measures as well as in verbal fluency with higher-dose (28 mg/day) memantine. WHAT THE READER WILL GAIN: Readers will become knowledgeable about this new dose and preparation of memantine. However, these advantages remain provisional and more research is needed to evaluate patient adherence, outcomes and caregiver burden related to twice-daily versus once-daily administration in patients with moderate to severe Alzheimer's disease. TAKE HOME MESSAGE: A new, once-daily, higher-dose preparation of memantine seems to be well tolerated and may provide additional benefits for selected patients with Alzheimer's disease.

Atypical antipsychotics and the risk of diabetes in an elderly population in long-term care: a retrospective nursing home chart review study.

OBJECTIVES: Although atypical antipsychotics (AA) are associated with weight gain and diabetes mellitus (DM) in younger patients, it is not known whether these drugs would have a detrimental effect on weight gain or diabetes in a long-term care elderly population. DESIGN: Retrospective chart review. SETTING: Two community nursing homes (NH). PARTICIPANTS: Charts of 1678 subjects admitted between 2000 and 2006 were screened; data from subjects on AA were analyzed. MEASUREMENTS: DM was defined by diagnosis in the Minimum Data Set (MDS), the prescription of diabetes medications, fasting blood glucose (BG) 126 mg/dL or higher, or random BG 200 mg/dL or higher. Worsening of DM was defined as beginning a medication in those treated with diet alone, or adding an additional medication to those already on antiglycemic therapy. RESULTS: There were 154 subjects on AA, mean age 82.8 +/- 8.0 (SD) years. Although there was no difference in age between the 101 women and the 53 men, there was a greater proportion of women 85 years or older compared with men (57% versus 40%, P = .04). Alzheimer's disease (AD) was diagnosed in 17% and non-AD dementia in 34%. Weight was normal (BMI less than 25 kg/m(2)) in 63%, overweight (BMI higher than 25 but less than 30 kg/m(2)) in 29%, and obese (BMI higher than 30 kg/m(2)) in 8%. Subjects were followed on AA for a median of 13.1 weeks (interquartile range 1.9-41.9). Despite these medications, 32% lost more than 5% of body weight. DM was an admitting diagnosis in 21%. There were 4 new and 5 worsening cases of DM during their stay in the nursing home; however, of these 9 cases, 4 occurred before the institution of AA. There was no increased frequency of weight gain or DM among the various atypical agents. CONCLUSIONS: In an elderly NH population, there was no evidence that short-term use (median 13.1 weeks) of atypical antipsychotic agents was associated with the onset or worsening of DM.