Indian Journal of PsychiatryIndian Journal of Psychiatry
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  Citation statistics : Table of Contents
   2009| January  | Volume 51 | Issue 5  
    Online since January 2, 2009

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Dementia: Merging frontiers and emerging vistas
TS Sathyanarayana Rao, MR Asha
January 2009, 51(5):2-4
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Dementia, a special supplement
TS Sathyanarayana Rao, KS Shaji
January 2009, 51(5):1-1
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Dementia care in developing countries: The road ahead
KS Shaji
January 2009, 51(5):5-7
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Reversible dementias
Manjari Tripathi, Deepti Vibha
January 2009, 51(5):52-55
In recent years, more attention has been given to the early diagnostic evaluation of patients with dementia which is essential to identify patients with cognitive symptoms who may have treatable conditions. Guidelines suggest that all patients presenting with dementia or cognitive symptoms should be evaluated with a range of laboratory tests, and with structural brain imaging with computed tomography (CT) or magnetic resonance imaging (MRI). While many of the disorders reported as 'reversible dementias' are conditions that may well be associated with cognitive or behavioral symptoms, these symptoms are not always sufficiently severe to fulfill the clinical criteria for dementia. Thus, while the etiology of a condition may be treatable it should not be assumed that the associated dementia is fully reversible. Potentially reversible dementias should be identified and treatment considered, even if the symptoms are not sufficiently severe to meet the clinical criteria for dementia, and even if partial or full reversal of the cognitive symptoms cannot be guaranteed. In the literature, the most frequently observed potentially reversible conditions identified in patients with cognitive impairment or dementia are depression, adverse effects of drugs, drug or alcohol abuse, space-occupying lesions, normal pressure hydrocephalus, and metabolic conditions land endocrinal conditions like hypothyroidism and nutritional conditions like vitamin B-12 deficiency. Depression is by far the most common of the potentially reversible conditions. The review, hence addresses the common causes of reversible dementia and the studies published so far.
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Frontiers in the pathogenesis of Alzheimer's disease
Kumar Sambamurti, KS Jagannatha Rao, Miguel A Pappolla
January 2009, 51(5):56-60
Alzheimer's disease (AD) is characterized by progressive dementia and brain deposits of the amyloid β protein (Aβ ) as senile plaques and the microtubule-associated protein, Tau, as neurofibrillary tangles (NFT). The current treatment of AD is limited to drugs that attempt to correct deficits in the cholinergic pathway or glutamate toxicity. These drugs show some improvement over a short period of time but the disease ultimately requires treatment to prevent and stop the neurodegeneration that affects multiple pathways. The currently favored hypothesis is that Aβ aggregates to toxic forms that induce neurodegeneration. Drugs that reduce Aβ successfully treat transgenic mouse models of AD, but the most promising anti-Aβ vaccination approach did not successfully treat AD in a clinical trial. These studies suggest that AD pathogenesis is a complex phenomenon and requires a more broad-based approach to identify mechanisms of neurodegeneration. Multiple hypotheses have been proposed and the field is ready for a new generation of ideas to develop early diagnostic approaches and develop successful treatment plans.
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Vascular cognitive impairment
Alladi Suvarna
January 2009, 51(5):61-64
The term vascular cognitive impairment (VCI) has been proposed to encompass all people with cognitive impairment of cerebrovascular origin. VCI is not a single condition, but has several clinical presentations, etiologies, and treatment. VCI forms a spectrum that includes vascular dementia, mixed Alzheimer's disease with a vascular component, and VCI that does not meet dementia criteria. Multiple pathophysiological mechanisms contribute to VCI, accounting for its heterogeneity. Although main changes in the brain in VCI include cerebral infarcts, vascular cognitive impairment is thought to be due to factors beyond acute infarcts. Cerebral white matter lesions and silent brain infarcts are considered to be risk factors for VCI. The prevalence of VCI is high and this entity is poised to become the silent epidemic of the 21st century. Cognitive impairment due to cerebrovascular disease can to some extent be improved, and VCI prevented, if vascular risk factors are brought under control and strokes do not recur. Therefore, strategies that focus on the prevention and treatment of the cognitive impairment associated with cerebrovascular disease are high priority healthcare objectives.
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Frontotemporal dementia: An updated overview
E Mohandas, V Rajmohan
January 2009, 51(5):65-69
Frontotemporal dementia (FTD) is a progressive neurodegenerative syndrome occurring between 45 and 65 years. The syndrome is also called frontotemporal lobar degeneration (FTLD). However, FTLD refers to a larger group of disorders FTD being one of its subgroups. The other subgroups of FTLD are progressive nonfluent aphasia (PFNA), and semantic dementia (SD). FTLD is characterized by atrophy of prefrontal and anterior temporal cortices. FTD occurs in 5-15% of patients with dementia and it is the third most common degenerative dementia. FTD occurs with equal frequency in both sexes. The age of onset is usually between 45 and 65 years though it may range anywhere from 21 to 81 years. The usual course is one of progressive clinicopathological deterioration with mortality within 6-8 years. Unlike Alzheimer's disease (AD), this condition has a strong genetic basis and family history of FTD is seen in 40-50% of cases. FTD is a genetically complex disorder inherited as an autosomal dominant trait with high penetrance in majority of cases. Genetic linkage studies have revealed FTLD loci on chromosome 3p, 9, 9p, and 17q. The most prevalent genes are PGRN (progranulin) and MAPT (microtubule-associated protein tau), both located on chromosome 17q21. More than 15 different pathologies can underlie FTD and related disorders and it has four major types of pathological features: (1) microvacuolation without neuronal inclusions, (2) microvacuolation with ubiquitinated rounded intraneuronal inclusions and dystrophic neurites FTLD-ubiquitinated (FTLD-U), (3) transcortical gliosis with tau-reactive rounded intraneuronal inclusions, (4) microvacuolation and taupositive neurofibrillary tangles. Behavior changes are the most common initial symptom of FTD (62%), whereas speech and language problems are most common in NFPA (100%) and SD (58%). There are no approved drugs for the management of FTD and trials are needed to find effective agents. Non-pharmacological treatment and caregiver training are important in the management of FTD.
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Memory clinics in context
David Jolley, Esme Moniz-Cook
January 2009, 51(5):70-76
The growing number of older people in all parts of the world raises the question of how best to respond to their health needs, including those associated with memory impairment. Specialist Memory Clinics have a role to play, complementing community services which reach out to older people with mental health problems and encompassing younger people who become forgetful. Dementia is the most common syndrome seen, but there are other important treatable conditions which present with subjective or objective dysmnesia. Memory Clinics provide a high quality, devoted focus for early intervention, treatment, support and research.
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Behavioral and psychological symptoms of dementia and their management
Nilamadhab Kar
January 2009, 51(5):77-86
Purpose: Behavioral and psychological symptoms of dementia (BPSD) are an integral part of dementia syndrome. They increase morbidity and burden, affect quality of life and impact cost of care. This review aims to study the features of BPSD, their assessment and management. Collection and Analysis of Data: Literature of BPSD was searched in PUBMED and the relevant cross references were accessed. Conclusions: Available literature suggests that BPSD can manifest in multiple ways; the common components are of behavioral, affective, psychotic and somatic in nature. There are specific rating scales for assessing BPSD; however, there is need for developing cross-culturally validated instruments. Nonpharmacological interventions are preferred as first line, which mainly include environmental modification, social interactions, minimizing effect of sensory deficits and behavioral interventions. The judicious use of medications such as cognitive enhancers, atypical antipsychotics and antidepressants has been suggested in acute, emergent situations or when BPSD do not respond to other interventions. There is a research need to address etiologies, social and economic impact of BPSD, efficacy of pharmacological and nonpharmacological treatments and cost-effectiveness of these interventions.
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The 10/66 dementia research group - 10 years on
Martin J Prince
January 2009, 51(5):8-15
Well-designed epidemiological research is relatively lacking in low and middle income countries where two-thirds of the world's estimated 24 million people with dementia live. The 10/66 Dementia Research Group has sought since 1998 to redress this imbalance. Pilot studies to develop and validate dementia diagnostic measures and study care arrangements in 26 centers worldwide were followed by one phase cross-sectional catchment area surveys in eight Latin American countries, China, India, Nigeria and South Africa. The protocol includes assessment of sociodemographics, disability, care arrangements, physical and mental health, and dementia diagnosis with (more restrictive) DSM-IV and (less restrictive) 10/66 dementia criteria. An incidence phase is underway in eight countries. 10/66 dementia prevalence is generally double that of DSM-IV dementia. DSM-IV dementia is particularly rare in India, attributable to the small proportion of family informants confirming cognitive decline and social impairment. Carer psychological and economic strain is as high as in the developed world, despite traditional family care arrangements. A significant minority of people with dementia are vulnerable due to lack of family support and economic resources. Earlier studies probably underestimated dementia prevalence in regions with very low awareness of this emerging public health problem. More research is needed to delineate the impact of dementia relative to other chronic diseases, and secular trends in countries experiencing rapid demographic ageing and health transition. Packages of care are also a priority - healthcare services and governments have not responded to families' complex needs for support in their long-term care role.
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Safety and efficacy of antipsychotic drugs for the behavioral and psychological symptoms of dementia
Chittaranjan Andrade, Rajiv Radhakrishnan
January 2009, 51(5):87-92
Background: Antipsychotic drugs are commonly used in the treatment of the behavioral and psychological symptoms of dementia (BPSD). Materials and Methods: We present a qualitative review of the data on the efficacy and safety of antipsychotic drugs for BPSD. We more specifically examine safety issues with an especial focus on recent research. We examine two safety studies in detail to provide readers with a critical perspective. Results: Typical and atypical antipsychotic drugs both attenuate the severity of BPSD; however, both categories of drugs increase the risk of cerebrovascular and other adverse events, as well as the risk of death. The risk appears greater with the typical drugs, with higher doses, and during the initial weeks of treatment. The risk probably persists for as long as a year after the initiation of treatment. Both drug- and patient-related factors appear to mediate this increase in risk. Conclusions: Antipsychotic drugs should be considered for BPSD only if there is a specific need, or if other treatments have failed; decision-making should be individualized and documented after a risk-benefit analysis. Atypical antipsychotics appear safer than the typical drugs. The lowest effective dose should be used.
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Closing the treatment gap for dementia in India
Amit Dias, Vikram Patel
January 2009, 51(5):93-97
There is a rich epidemiological evidence base on dementia in India which shows that this neurodegenerative condition is an important public health problem, particularly in the context of the rapid demographic transition in many parts of the country. Research has shown that most people with dementia, and their caregivers, have significant unmet health and social welfare needs. Due to the great shortage of health care resources and the low levels of awareness about dementia, interventions addressing the needs of the people should be home based and directed at improving quality of life of the person with dementia and the caregiver. In view of the lack of specialists to deal with dementia, a group in Goa developed an alternate model of care which involved training lay health workers to provide home-based care for people with dementia under the supervision of a psychiatrist. This was successfully implemented and evaluated in a randomized controlled trial which showed clear benefits. This article concludes by considering the implication of these findings on strategies for scaling up services and close the treatment gap for dementia in India.
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Harnessing brain and cognitive reserve for the prevention of dementia
Michael Valenzuela, Perminder S Sachdev
January 2009, 51(5):16-21
The concepts of brain and cognitive reserve capture several elements of common wisdom - that we all differ in the neural resources we are endowed at birth, that experience and especially complex mental activities then modify how these neural resources are organized and cultivated, and that after any form of brain injury there is significant individual variation in the degree to which clinical deficits may manifest. Transforming these insights into a formal and refutable working definition, however, has been more challenging. Depending on the scale of analysis, brain and cognitive reserve have been defined from neurocentric, neuropsychological, computational, and behavioral perspectives. In our research, we have focused on the behavioral definition, whereby an individual's lifetime exposure to complex mental activities is used for prediction of longitudinal cognitive and neurological change. This approach also benefits from a wealth of epidemiological studies linking heightened complex mental activity with reduced dementia risk. Research in the field of cognitive training is also beginning to indicate that incident cognitive decline can be attenuated, with recent clinical trials addressing the major challenges of transfer of gain and durability of effect. High quality randomized clinical trials are therefore the most urgent priority in this area so that the promise of brain and cognitive reserve can be harnessed for the purpose of the primary prevention of dementia.
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Social networks and their role in preventing dementia
Jagan A Pillai, Joe Verghese
January 2009, 51(5):22-28
Interest in the role of social networks as a protective factor in the development of dementia over the last decade has increased with a number of longitudinal studies being published on the possible association of different lifestyles with dementia. This review examines and provides a summary of the published longitudinal studies exploring the effect of social network on dementia, with particular focus on their relevance to the Indian society. Potential cognitive and biological mechanisms mediating the effects of social networks on dementia are discussed. Results from observational studies suggest that degree of social engagement, marriage, living with someone and avoiding loneliness may have a protective effect on developing dementia that could be applicable to both Indian and western societies. A deeper analysis of the nature of social networks and dementia pertinent to Indian society is awaited.
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Depression, cognitive impairment and dementia: Why should clinicians care about the web of causation?
Mary Ganguli
January 2009, 51(5):29-34
Depression, cognitive impairment and dementia are all common in older adults. The relationship between them is bi-directional and complex. The literature on the subject is growing and fascinating but also riddled with apparent inconsistencies. This brief review attempts to clarify and integrate information from clinical, laboratory, and community studies and to draw some inferences of potential relevance to clinicians.
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Type 2 diabetes mellitus, cognition and brain in aging: A brief review
Rajeev Kumar, Jeffrey CL Looi, Beverley Raphael
January 2009, 51(5):35-38
Diabetes mellitus is a complex disease with many potential complications. Whilst there have been inconsistent results in regard to an association between cognition and type 2 diabetes, there is evidence that verbal memory and processing speed are the cognitive domains usually impaired. In elderly diabetic subjects, other cognitive domains may also be involved, due to ageing. Glycemic control is implicated in the development of cognitive dysfunction, although more research is needed in this area. Insulin dysregulation and hyperglycemia play an important role in neurodegeneration. Using structural neuroimaging, it has been shown that brain atrophy is an important feature in those with type 2 diabetes. Integrative research is needed using behavioral, cognitive, imaging, and genetic platforms.
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Prevention of dementia: Role of vascular risk factors and cerebral emboli
Nitin Purandare
January 2009, 51(5):39-43
Dementia is a major health problem worldwide and the number of people affected is expected to rise considerably, especially in developing countries like India. Vascular risk factors are involved in causation of both vascular dementia and Alzheimer's disease (AD), account for 90% of all dementias. A selective review of the literature was conducted to summarize the current evidence from clinical studies to examine the role of vascular risk factors in prevention of dementia. Epidemiological evidence suggests that control of vascular risk factors may prevent, or at least delay, the onset of dementia. This finding is supported to some extent by randomized controlled trial evidence for treatment of hypertension but not for other risk factors. However, a number of methodological issues need addressing. There is a need for a randomized controlled trials (RCT) targeting multiple vascular risk factors in patients at increased risk of dementia; i.e., those with mild cognitive impairment. The research should also explore novel risk factors and mechanisms of vascular brain damage. For example, asymptomatic spontaneous cerebral emboli have been shown to be more frequent and associated with a more rapid progression of dementia in both AD and vascular dementia.
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Mild cognitive impairment: The dilemma
Charles Pinto, Alka A Subramanyam
January 2009, 51(5):44-51
Memory complaints are ubiquitous in our aging population. Many older adults fear that today's forgetfulness will usher in tomorrow's dementia. Mild cognitive impairment (MCI) is considered by many as an intermediary stage for dementia. Though the nomenclature has been varied and extensive, the criteria by the American Academy of Neurology and the EADC have been helpful. Prevalence rates varying from 3% to as high as 59% with a conversion rate to dementia varying from 8 to 15% only increases the need for diagnostic tests and markers which are in the form of neuropsychological tests, neuroimaging and other biological markers. Medications indicated for treatment of mild to severe Alzheimer's Disease (AD) are offered to persons with MCI with a varying type of response which does not hold in the long run to newer strategies of exploring disease modifying drugs which hold a better promise. This benefit with management of risk factors like hypertension and diabetes coupled with non-pharmacological approaches like exercise and social networking has thrust upon us the necessity for coordinating our efforts to improve detection and management of MCI.
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