Basil J. Pillay

Mild cognitive impairment and dementia in a heterogeneous elderly population: prevalence and risk profile

OBJECTIVE To describe the demographic, clinical and risk profile of Mild Cognitive Impairment and dementia in a sample of elderly South Africans within a residential setting. METHOD One hundred and forty participants residing in a group of residential homes for the elderly were assessed by psychiatrists and assigned diagnoses of dementia or Mild Cognitive Impairment (MCI). Participants diagnosed with dementia were also offered haematological investigations and a CT scan of the brain. RESULTS The sample consisted of 140 participants comprising 46.4% White, 29.3% Coloured, 20% Asian and 4.3% Black participants. There were 97 (69.3%) females and 106 (75.7%) participants had less than 12 years of education. Eleven (7.9%) dementia and 38 (27.1%) MCI cases were diagnosed. Increasing age was associated with cognitive impairment (MCI and dementia) (p=.020) but there was no association between gender and cognitive impairment (p=.165). MCI was significantly associated with a lower education level (p=.036) and no association was found between depression (current-p=.646; past-p=.719) and dementia or MCI. The presence of vascular risk factors (n=140) ranged from 66.4% (hypertension) to 14.3% (stroke). Subjective memory complaints were significantly associated with cognitive impairment (p=.001). Except for the use of the telephone (p=.225) and the television (p=.08), impairment in all domains of instrumental activities of daily living that were assessed were significantly associated with a dementia diagnosis. CONCLUSION The study showed that cognitive impairment was associated with increasing age and low education levels. The presence of vascular risk factors places this population at risk for future cognitive decline.

Sexual abstinence and HIV knowledge in school-going adolescents with intellectual disabilities and non- disabled adolescents in Nigeria

Objective The study compared sexual practices and predictors of sexual abstinence among adolescent learners with mild/moderate intellectual impairments and their non-disabled peers in Nigeria. Method This was a comparative, cross-sectional survey that assessed sexual practices of learners with mild/moderate intellectual impairments (N = 300) and non-disabled learners (N = 300), aged 12–19 years, in Oyo State, Nigeria. Data were analysed using SPSS 15.0. Results Findings indicated that learners with mild/moderate intellectual impairments abstained from sex less than non-disabled adolescents (p = 0.002). Girls with intellectual disabilities were almost four times more likely to report history of rape than non-disabled girls. There was no significant difference between sexually abstinent and sexually experienced learners with intellectual disabilities (p = 0.671) and non-disabled adolescents (p = 0.181) in their mean HIV transmission knowledge scores. Many factors, including being male, social supports and self-efficacy determined sexual abstinence among adolescents. Conclusions Although sexual abstinence is the recommended HIV-prevention strategy in HIV prevention curriculum in Nigerian schools, findings of this study suggested that sexual abstinence alone may not be effective for adolescent learners with intellectual disabilities. Interventions targeting youth with intellectual disabilities should consider all these factors.

Screening a heterogeneous elderly South African population for cognitive impairment: the utility and performance of the Mini- Mental State Examination, Six Item Screener, Subjective Memory Rating Scale and Deterioration Cognitive Observee.

OBJECTIVE The aim of this study was to report on the prevalence of cognitive impairment, and to assess the performance and utility of subjective, objective and informant screening tools in a heterogeneous community sample. METHOD A sample of 302 elderly participants (>60 years) living in residential homes in a large city in South Africa were screened for the presence of cognitive impairment using objective (Mini-Mental State Examination [MMSE] and Six Item Screener-[SIS]), subjective (Subjective Memory Complaint [SMC]and Subjective Memory Rating Scale [SMRS]) and informant (Deterioration Cognitive Observee [DECO]) screening tools. All tools were compared to the MMSE and the influence of demographic variables on the performance on these tools was considered. RESULTS Significantly lower MMSE scores were found in participants aged 80-89 years (p=.023) and those who had 8-11 years of education (p=.002). For every one additional year of education, participants were 0.71 times less likely to screen positive on the MMSE. Differential item functioning on various components of the MMSE was demonstrated due to the effects of education, race and gender. There was significant differential performance between the recommended and alternate attention/concentration items (p<.001) with the alternate item favouring better performance. Based on the MMSE cutoff score of < 23, the prevalence of cognitive impairment was 16.9%; the prevalence yielded by the remaining tools ranged from 10.5% using the DECO to 46% as determined by the presence of a SMC. Using the MMSE as the reference standard for the presence of cognitive impairment, the SIS, SMC, SMRS and DECO had sensitivities of 82.3%, 54.6%, 17.0% and 37.5%, and specificities of 71.3%, 57.6%, 87.4% and 96.7% respectively. Age and race influenced performance on the MMSE, SIS and SMRS. CONCLUSION Different types of cognitive screening tools yielded varying sensitivities and specificities for identifying cognitive impairment when compared to the MMSE. The influence of race, age and education on test performance highlights the need for suitable, culture-fair screening tools. Locally, the alternate item for attention/concentration should be preferred.

Post-traumatic stress disorder in patients with spinal-cord injuries

The majority of spinal-cord injuries result from traumatic incidents such as motor vehicle accidents, falls, and acts of violence such as stab and gunshot wounds. Given the traumatic and life-threatening nature of most spinal-cord injuries, especially in a country like South Africa, where there is a high level of violent crime, post-traumatic stress disorder can be a common consequence for many patients. Using a prospective design, a total of 112 traumatic spinal-cord-injured patients, drawn from government hospitals in the Durban (South Africa) metropolitan and surrounding areas, were assessed. The control group consisted of 79 patients who had amputations. Post-traumatic stress disorder was assessed using the Impact of Event Scale–Revised and Post-Traumatic Diagnostic Scale. In addition, a semi-structured interview was conducted and supplementary data were obtained from each patient’s file. The results indicated a high rate of post-traumatic stress disorder following traumatic spinal-cord injuries. Road traffic accidents were the most common cause of traumatic spinal-cord injuries. Single young males were found to be at greater risk of sustaining such injuries. The results and discussion emphasise the ubiquitous multicultural issues that influence outcomes. This study highlights the need for psychological intervention following traumatic spinal-cord injuries due to the high rate of post-traumatic stress disorder symptoms.

Diabetes distress and related factors in South African adults with type 2 diabetes

Background: In South Africa, the prevalence rate of diabetes is 9.27%, with an estimated 2.6 million people living with the disease. Diabetes-related distress has been described as encompassing the patient’s concerns about the self-management of diabetes, perception of support, emotional burden and access to quality health care. There has been little or no research done in South Africa regarding diabetes-related distress. Objectives: The aim of this paper was: (1) to identify the level of diabetes-related distress in a cohort of diabetes type 2 patients in KwaZulu-Natal and (2) to identify the factors that contribute to diabetes-related distress. Methods: This cross-sectional study was conducted at two public facilities and five private medical practices on the north coast of KwaZulu-Natal, South Africa. The Diabetes Distress Scale was administered, together with a demographic questionnaire, to 401 participants. Results: In total, 44% of the sample reported having moderate to high levels of distress. The mean scores of the Emotional Burden dimension (M = 2.6; SD = 1.42) and the Regimen Distress dimension (M = 2.33; SD = 1.29) suggested moderate levels of distress. Factors that significantly contributed to high levels of distress were younger age, high HbA1C levels, female gender, attending the public health sector, unemployment and being a person of colour. Conclusion: Healthcare providers need to pay particular attention to the psychological needs of the patient, which impact on the medical outcomes of the disease.

Anxiety, depression and psychological well-being in a cohort of South African adults with Type 2 diabetes mellitus

Background The prevalence of diabetes mellitus (DM) has increased at alarming rates globally. South Africa has the second highest number of people in Africa living with DM, with prevalence rates being among the top five countries in Africa. Accordingly, psychological issues associated with DM have been a growing focus of attention. Studies have found that patients with DM have elevated levels of anxiety and depression, and decreased levels of well-being. In South Africa, there is a paucity of studies on the psychological issues associated with DM. Objectives The aim of this paper was to explore the prevalence and association of anxiety, depressive features and psychological well-being in patients with Type 2 DM. Method In a cross-sectional survey, patients with Type 2 DM were recruited from public and private facilities. The Hospital Anxiety and Depression Scale (HADS), the General Health Questionnaire (GHQ-28) and WHO-5 Well-being Index (WHO-5) were administered. Results Four hundred and one participants completed the questionnaires. On the WHO-5, 277 (69%) reported good well-being, while 124 (31%) indicated poor well-being and were considered at risk for depressive features. On the HADS, 186 (46%) had mild-to-severe depressive features and 128 (32%) had mild-to-severe anxiety. There was a strong negative correlation between the WHO-5, HADS and General Health Questionnaire (GHQ) scales, which indicated that an increase in anxiety and depressive features decreased psychological well-being. Conclusion Health-care providers should identify and treat anxiety and depression as a standard part of diabetes care. Patients should also be referred to the appropriate mental health professional as part of the management of diabetes.

Socioeconomic status, family-related variables, and caregiver-adolescent attachment

Associations between financial disadvantage, family structure, and indicators of the caregiver–adolescent relationship and family functioning were examined in a sample of 206 families recruited from low socioeconomic status (SES) communities in Durban, South Africa. Participants included a maternal caregiver and an adolescent (65.5% female) from each family; adolescents were in Grade 7 (n = 175) or Grade 10 (n = 31). Data were collected via home interviews. The sample was diverse in terms of race. One-fifth of the sample reported a household income of R1500 or less; two-thirds of the sample earned R5000 per month or less. Median level of caregiver education was Grades 9–11. Just under half (45.1%) of the adolescents lived with both parents. Indicators of SES were household income and maternal education. Since financial resources and family structure are associated, a series of regression analyses with household income, parental education, and family structure as the predictors were used to examine associations with adolescent- and parent-reported family functioning and with youth reports of caregiver support and attachment. In the models predicting adolescent attachment, income was the only unique predictor, with higher household incomes associated with less anxious attachment relationships. For the model predicting perceived support from mother, maternal education was the only unique predictor. Higher maternal education was associated with more perceived support. The models predicting support from father, or parent- or adolescent-rated family functioning were not significant. These data contribute to our understanding of linkages between structural indicators and family relationships.

Community violence exposure, family management practices, and substance use in youth: a cross-cultural study

Associations between community violence exposure, family management practices, and substance use were compared in a sample of early adolescents in low-income communities from the United States (N = 151; M age = 12.71 years, standard deviation = 0.65; 50.3% female) and South Africa (N = 175; M age = 12.55 years, standard deviation = 0.85; 64.6% female) using home interviews with youth and their maternal caregivers. Past year victimization was associated with recent youth substance use. The moderating role of family management practices varied by type of practice (e.g., parental knowledge, control, solicitation, or child disclosure), reporter, and country. High parental knowledge reported by caregiver was protective against substance use only for South African youth. In youth reports, parental knowledge was protective across the United States and South Africa. Youth reports of their disclosure to parents were negatively associated with substance use in the United States but not South Africa. These data highlight the importance of considering both ecological context and reporter in the links between violence exposure, parenting, and substance use in youth.

Social support and coping in adults with type 2 diabetes

Background The diagnosis of diabetes has been described as a lifelong psychological burden on the patient and his or her family. Social support plays a pivotal role in patients with diabetes and is important in enabling them to cope effectively with the disease. There is a dearth of research on social support and coping in patients with diabetes in South Africa. Objectives The aim of this study was to explore whether patients with poor perceived social support have lower levels of well-being and coping than patients with good social support. Method A cross-sectional study was conducted at both public and private facilities on the north coast of KwaZulu-Natal, South Africa. The Diabetes Care Profile (DCP), the General Health Questionnaire (GHQ), the Social Support Questionnaire (SSQ) and the WHO-5 Well-being Index (WHO-5) were administered to 401 participants. Results The findings indicate that there is an inverse relationship between social support and coping, which suggests that an increase in social support is associated with a decrease in emotional distress. There was a small positive correlation between the SSQ and the WHO-5, which suggests participants who had good support endorsed better levels of well-being. Although participants indicated that they were satisfied with their level of support, they had poor coping as indicated by the high mean score on the GHQ and the high HbA1c level. There was a small positive correlation between GHQ and HbA1c. There was no association between social support and HbA1c. Conclusion Social support is important in helping the patient with diabetes cope with the disease and to improve adherence to treatment. Health care providers should take cognisance of psychosocial factors in the treatment regime of the patient. Family members should be educated about diabetes, the importance of adherence and long-term complications of the disease.

A situation analysis of psychiatrists in South Africa’s rural primary healthcare settings

Background South Africa (SA) has been facing serious challenges in providing human resources for the delivery of essential mental health (MH) services. The majority of its prescribing MH specialists, psychiatrists, practise in private, urban and peri-urban areas. The findings of a situation analysis audit of psychiatrist human resources in the public rural primary healthcare (PRPHC) sector are presented in this paper. Method This audit was based on both primary and secondary data. The primary data were obtained from key informant interviews with the clinical heads of 160 PRPHC facilities, while the secondary data comprised a literature review. Results The results indicate that psychiatrists are severely underrepresented, employed at a rate of 0.03 per 100 000 population in SA’s PRPHC settings. Conclusions Because of a lack of MH nurses and medical officers dedicated to MH in PRPHC facilities, recommendations are made that the current task shifting strategy be revisited to include more cadres of MH professionals with specialised psychopharmacological training, as non-medical prescribers at PRPHC level. It is advised that visiting psychiatrists and family physicians be involved in the construction of training and supervision programmes for non-medical prescribers at the primary healthcare level.