V. De Silva

Validation of the Sinhala version of the Montreal Cognitive Assessment in screening for dementia

OBJECTIVES To validate the Sinhala version of the Montreal Cognitive Assessment (MoCA) scale in screening for dementia. METHODS The MoCA translation and cultural adaptation was carried using a combined qualitative and quantitative approach. Sample size was calculated to detect a targeted sensitivity of 85% and a specificity of 85%. Sample consisted of 49 participants diagnosed with dementia of the Alzheimers type (AD) according to DSM-IV criteria and 49 normal controls (NC) aged ≥50 years. All subjects were administered the Mini Mental State Examination (MMSE) and MoCA Sinhala version (MoCA-S). Concurrent validity was assessed using Pearson correlation coefficients between the MoCA-S scores and MMSE scores. Criterion validity was assessed using receiver operating characteristic (ROC) analysis. RESULTS Mean MoCA scores between NC (26.71, SD 2.4) and AD group (16.78, SD 5.9) were significantly different (t=10.8, p<0.001). Cronbachs alpha of 0.818 indicated good internal consistency. Attention (digit span, sustained attention, and the serial 7 calculation task) had the highest discriminant ability followed by visuospatial skills (trail making, cube drawing and clock drawing). Naming had poor discriminant ability. There was a high, positive correlation between MoCA-S total scores and MMSE total scores. (r=0.907, p<0.001). The area under the ROC curve was 0.975 (95%CI 0.94-1.0) for the MoCA and 0.928 (95% CI 0.87-0.98) for MMSE. A cut-off value of 24 provided the best balance between sensitivity (98.0 7%) and specificity (79.6 %). CONCLUSION MoCA-S is a valid and reliable instrument which can be used as a brief screening instrument for dementia in Sri Lanka.

Geographical variation in admissions due to poisoning in Sri Lanka: a time series analysis

OBJECTIVES To carry out time series analyses of hospital admissions for poisoning between 1995-2008 in all districts in Sri Lanka to identify trends and geographical variations in the substances used in poisoning. METHODS Data of hospital admissions from 1995-2008 due to poisoning were obtained from the Annual Health Bulletins published by the Ministry of Health. Data were converted to annual rates per 100,000 population. Time trends in the rates of suicide and self-poisoning were calculated using univariate time series analysis. RESULTS All districts except Kilinochchi and Mullaitivu showed an increase in the rates of admissions due to poisoning with drugs, medicaments and biological substances. Colombo, Hambantota, Kalutara and Anuradhapura showed an exponential increase. Hambantota, Monaragala, Nuwara Eliya and Colombo show an increase in the rate of admissions after pesticide poisoning. All other districts showed a linear decrease. Admissions due to all types of poisoning showed a negative trend in Anuradhapura, Polonnaruwa, Ampara, Matale and Batticoloa districts. Other districts show a positive trend in the rate of admissions for all types of poisoning. CONCLUSIONS Results should be viewed with caution because they are based on analysis of secondary data. Although the rate of suicides has reduced since 1995, admissions due to self poisoning have increased in almost all districts. While pesticide poisoning is becoming less, there is a gradual shift to the use of drugs and medicaments in self poisoning. Poisoning with drugs, medicaments and biological substances are increasing both in urban and rural areas.

Direct and indirect cost of schizophrenia in outpatients treated in a tertiary care psychiatry unit

OBJECTIVE To estimate the direct and indirect cost of care incurred by patients with schizophrenia attending a tertiary care psychiatry unit in Colombo. METHODS Study was carried out at the National Hospital of Sri Lanka. Systematic sampling selected every second patient with an ICD-10 clinical diagnosis of schizophrenia presenting to the clinic during a two month period. Investigator administered semi-structured questionnaire was used for data collection. RESULTS Sample consisted of 91 patients. Direct cost was defined as cost incurred by the patient (out of pocket expenditure) for outpatient care. Mean cost of a clinic visit was Rs. 500. Of the clinic visit cost, highest proportions were travel cost (39.8%) and medication (26.4%). Sixty four (70.3%) had received informal care. The mean cost of informal care during the entire course of the illness was Rs. 33, 540. Mean indirect cost was Rs. 150,190. CONCLUSIONS Despite low direct cost of care, indirect cost and cost of informal treatment results in substantial economic impact on patients and their families. It is recommended that economic support should be provided for patients with disabling illnesses such as schizophrenia, especially when patients are unable to engage in full time employment. There is a need to educate the public regarding higher cost of care by traditional healers and other informal modes of treatment compared to Western medical care.

Clozapine-associated weight loss

Clozapine is associated with weight gain. We report three patients with substantial weight loss following treatment with clozapine. The weight loss observed in the three patients was 33, 18 and 14.4 kg with percentage loss of body weight of 49, 18 and 21 respectively. Two patients had diabetes mellitus. History, physical examination and extensive investigations in the three patients did not reveal any cause that could account for the weight loss.

Lower Estimated Glomerular Filtration Rates in Patients On Long Term Lithium; a Comparative Study and a Meta-analysis of Literature

Several studies have shown that long term lithium use is associated with a subtle decline in estimated glomerular filtration rate (eGFR). Lithium can be a risk factor for chronic kidney disease in long term users. Objective To compare eGFR values of patients on long term lithium compared to controls matched for age, sex and confounding comorbidities Methods Patients with bipolar affective disorder, who are on lithium (for at least a year), were compared against controls matched (1:1) for age, gender and presence or absence of diabetes and hypertension. The eGFR was calculated according to the modification of diet in renal disease study formula. A meta-analysis was performed to compare our findings with similar studies in literature. Results Forty seven patients met the inclusion criteria. They were matched with 47 controls. The eGFR values of lithium users were significantly low (p = 0.04) compared to controls and the mean decline in eGFR was -2.7 ml/min/1.73m2(SD ± 9.8) per year. The significant difference in eGFR persisted between the subgroup without comorbidities (diabetes and hypertension) and their controls but disappeared for subgroup with comorbidities and their controls. Nevertheless, lithium users had a lower eGFR in both subgroups. A meta-analysis of 9 studies showed a significant lowering in the glomerular filtration rate in lithium users compared to controls [mean difference -10.3 ml/min (95% confidence interval: -15.13 to -5.55, p Conclusions Lithium causes a subtle decline in glomerular filtration rate and renal functions need to be monitored in lithium using patients.

Are Urinay Tract Infections Associated with Acute Episodes of Schizophrenia

Objectives To establish any association between urinary tract infections and acute episodes of schizophrenia Methods A Case control study conducted in University Psychiatry unit, National Hospital of Sri Lanka (NHSL), Colombo, Sri Lanka. Thirty four cases with acute episode of schizophrenia and 30 normal controls matched for age and gender were selected. Cases were patients who met the International Classification of Disease (ICD- 10) criteria to diagnose schizophrenia who attended the inward and outpatient care of the unit. Urine full report (UFR) and urine culture were performed in all cases and controls to detect and confirm urinary tract infections (UTI). Data was analyzed using SPSS software. Results Number of cases was 34 and controls were 30. Mean age of cases was 34.8 years while in controls it was 34.1 years. In cases 18 (52.9%) were males and in controls, 16 (53,3%) were males. Among patients who had acute episodes of schizophrenia 5 (14.7%) became positive for UFR and from controls 2 (6.6%) became positive. (Odds ratio=2.4). Urine culture was positive in 1 case and 1 control each. (Odds ratio=0.88). Conclusions Patients with acute schizophrenia are more likely to have positive urine full report than normal healthy controls. But they are not more likely to experience urinary tract infections than the normal healthy controls during their acute episode of schizophrenia.

The Common Side Effects of Long Term Treatment with Clozapine and Their Impact: a Sri Lankan Experience

Objectives To analyse the side effects experienced by patients who are on clozapine for a period of more than one year and to analyse the impact of the side effects. Methods A descriptive cross sectional study carried out in University Psychiatry unit, National Hospital of Sri Lanka, Colombo. All patients attending the clozapine clinic within one month and who are on clozapine for a period of more than one year and who are in remission were selected. Interviewer administered questionnaire was used to assess the presence of side effects and their impact. Data was analyzed using SPSS software. Results Sample was 63. Mean age was 34.9 years (range 18-60). Mean duration of usage of clozapine is 7.0 years (range 1-20). Fifty seven (71.4%) had hyper-salivation and constipation and 12 (19.0%) had nocturnal enuresis. Majority of patients who had hyper-salivation (86.6%) and nocturnal enuresis (100%) were not receiving any medical intervention. Fifteen (23.8%) reported the side effects have caused distress for them and 19% (n=12) revealed they have affected their activities of daily living. Conclusions Most common long term side effects were hyper-salivation and constipation. Majority of patients with hyper-salivation were not receiving medical intervention. Majority of patients did not report that the side effects affect their activities of daily living or they cause personal distress.

EPA-0130 - Analysis of the behaviour and psychopathology in patients with mania

Introduction Mania is a syndrome characterized by elevation of mood, increased activity and self important ideas. Inflated self-esteem may develop into grandiose delusions and suspiciousness into delusions of persecution. Grandiose delusions can be classified into three types. They are delusions of grandiose ability, grandiose identity and religious delusions. Studies on the content of the grandiose delusions and other psychopathology in patients with mania in Sri Lanka is scarce. Aims To analyze the behavior and psychopathology in patients with mania Methods Descriptive cross sectional study. All patients admitted to University Psychiatry Unit, National Hospital of Sri Lanka (NHSL) who met ICD 10 criteria of first episode mania and Bipolar Affective Disorder, current episode manic, within a period of three months were selected. Interviewer administered questionnaire and clinical records were used. Results Sample was 36. Twenty two (61.1%) had manic episode with psychotic symptoms. Thirteen (36.1%) had destructive behaviour. Thirty three (91.6%) did not show sexual disinhibition. Eighteen (50%) had grandiose delusions. Of the grandiose delusions 10 (55.5%) were of grandiose ability, 6 (33.3%) were of grandiose identity and 2 (11.1%) were of the religious subtype. Five (50%) who had delusion of grandiose ability believed they had healing power. Eleven (30.5%) had persecutory delusions and seven (19.4%) had delusions of reference. Five (13.8%) had auditory hallucinations. Conclusions Grandiose delusions were the commonest type of delusion but almost one third had persecutory delusions. Most common subtype of grandiose delusion was grandiose ability. Most common content of grandiose ability was healing power.