This is a model answer of Critical Review paper for Malaysian postgraduate examination in psychiatry. This model answer was used for marking the review paper for Master of Medicine (Psychiatry) and Master of Psychological Medicine, May 2009.

This case report highlights the issue of hypersexuality in persons with dementia and outlines the possible etiology and challenges associated with interventions of inappropriate sexual behaviors in dementia. Methods: We report a 75-year-old male with vascular dementia who developed hypersexuality and aggression towards his wife. The management plans are elaborated in this paper. Results: A combination of pharmacological and psychosocial intervention lead to the resolution of his inappropriate sexual behavior and improvement in his relationships with his wife and children. Conclusion: Inappropriate sexual behaviors need to be recognized and managed without compromising the fulfillment of the human’s basic need of sexuality.

Objective: To study the effect of depressive disorders, severity of depression and, sociodemographic factors on drug compliance among hypertensive patients at primary care clinics. Methods: A total of 201 hypertensive patients on treatment for at least 3 months who attended the HUKM Primary Care Clinic and Salak Polyclinic were selected for this study. Patients were screened for depressive disorders using the Hospital Anxiety Depression Scale (HADS) and those who scored 8 and more were further interviewed to establish a diagnosis using the Mini International Neuropsychiatric Interview (MINI). Patients who were diagnosed to have depressive disorders were further rated for the severity of the illness by using Hamilton Rating Scale for Depression (HAMD). Drug compliance was assessed during a 2 month follow up using the pill counting method (ratio 0.8 – 1.2 considered as compliant). Results: The prevalence of non-compliance among hypertensive patients was 38.3%. There was no association between the diagnosis of depressive disorders and drug compliance. Among the 12 patients who had depressive disorders, severity of depression as rated by HAMD, showed significant association with drug compliance (Mann-Whitney test z = -2.083, p<0.05).Conclusion: The results suggested that severity of depression has significant association with poor compliance to medical treatment. It is therefore very important to identify and treat depression to avoid poor drug compliance and further complications related to hypertension.

Making a medical diagnosis in an elderly person presenting with first time psychiatric symptoms can be challenging. A 61 year old lady presented with 4 years history of tactile hallucinations in her legs and delusions of persecution, and 2 weeks history of depression and mild cognitive impairment. There were no other significant physical findings, except for dysarthria and fine bilateral hand tremors. As patient had no prior psychiatric history, she was investigated for differential diagnoses of late-onset schizophrenia, psychotic depression and early dementia. A thorough investigation for concomitant medical illnesses was done which revealed low serum calcium, high serum phosphate and relatively low serum parathyroid hormone levels. A diagnosis of Fahr’s syndrome (FS) was made based on history, hematological findings of idiopathic hypoparathyroidism and bilateral basal ganglia calcifications (BGC) on neuroimaging. Treatment of FS is non-specific and mainly symptomatic. This patient improved with treatment comprising antidepressant, antipsychotic and calcium supplement.

The quality of relationship between a person with dementia and a family caregiver has been identified as one of important factor in informal dementia care. Currently there is no validated questionnaire to measure the dyadic relationship in Malaysia. The aim of present study is to examine the reliability and validity of Quality of the PatientCaregiver Relationship (QCPR) questionnaire in Malay version. A total of 70 patients with mild to moderate dementia and their caregivers were recruited from the psychogeriatric clinic, Universiti Kebangsaan Malaysia Medical Centre using a cross sectional study. The QCPR questionnaire was translated into Malay following the standard guidelines for crosscultural adaptation of measure. The person with dementia and their caregiver completed the QCPR Malay version separately. Internal consistency and test-retest examined for reliability. Construct validity was tested with principal component factor analysis. The reliability of patient QCPR Malay version was good with Cronbach’s alpha coefficients of 0.86 and intraclass correlation coefficients of 0.85. Item 11 was omitted from the caregiver QCPR Malay version due to its poor correlation with the corrected item-total score. The newly formed scale, 13 items caregiver QCPR Malay version, had satisfactory reliability (Cronbach’s alpha 0.89 and intraclass correlation coefficients 0.91). Principal component factor analysis extracted 4 factors for patient version and 3 factors for caregiver version which explained 69.44% (patients’ report) and 61.20% (caregivers’ report) of the total variance of the scale. As a conclusion, both the patient (14 items) and caregiver (13 items) adapted QCPR Malay version is a reliable and valid tool to measure the quality of dyadic relationship between people with mild to moderate dementia and the caregiver.
Informal care ; dementia ; caregiver ; questionnaire ; reliability ; validity

The Quality of Life-Alzheimer’s Disease (QOL-AD) questionnaire is a reliable, valid and popular outcome measure in dementia related studies. However, to date there is no published report on adopted version of QOL-AD in Malay language. Thus this preliminary study aimed to evaluate the reliability and validity of the QOL-AD in Malay language for patients with dementia and to examine the level of agreement between patient-caregiver as a proxy reports on patient’s quality of life. A total of 65 patients with mild to moderate dementia and their caregivers were recruited from the psycho-geriatric clinic, Universiti Kebangsaan Malaysia Medical Centre using a cross sectional study design. The QOL-AD was translated into Malay language using the standard guidelines for cross-cultural adaptation of measure. The patient-caregiver dyads completed the QOL-AD in Malay language separately. Test-retest and internal consistency was evaluated for reliability and construct validity was tested with principal component factor analysis. The reliability of QOL-AD in Malay language was good with Cronbach alpha coefficients of 0.82 and 0.79 and intraclass correlation coefficients of 0.77 and 0.89 for patients and caregivers report respectively. Meanwhile a positive moderate agreement was achieved between patient and caregiver rating (r=0.60, p<0.01). The principal component factor analysis extracted 4 factors for both patient and caregiver reports which explained 66.02% (patients’ report) and 64.24% (caregivers’ report) of the total variance of the scale. As a conclusion, the QOL-AD in Malay language is a reliable and valid tool to measure the quality of life of people with mild to moderate dementia.

Subclinical hypothyroidism (SHT) is a biochemical diagnosis, defined as an elevated Thyroid Stimulating Hormone (TSH) with normal free thyroxine (FT4). It affects 4-10% of the adult population and is more prevalent in elderly women. Its commonest cause is autoimmune thyroiditis, detected by antithyroid peroxidase antibody (TPO-Ab). About 2-5% of SHT patients progress to overt hypothyroidism annually. The SHT prevalence among depressed patients ranges between 3% and 17%. This study aimed to determine the prevalence of SHT and TPO-Ab positivity among patients diagnosed with depressive disorders. It was a cross-sectional study carried out in the Universiti Kebangsaan Malaysia Medical Centre over a 12 months period. Serum TSH, FT4 and TPO-Ab were measured. Results showed that 82% of depressed patients were euthyroid, 4% had SHT, 11% had subclinical hyperthyroidism and 2% had discordant thyroid function. TPO-Ab positivity among the subjects was 7%, one of whom had SHT. In conclusion, the prevalence of SHT and TPO-Ab positivity in the study population, at 4% and 7%, respectively, were comparable to previous findings.
Depression

Sleep quality can vary in relation to one’s general well-being and in the elderly, it is often affected by the presence of medical or psychological conditions. This study aims to determine the frequency of different components of sleep quality in the elderly, and their relationships with psychosocial and medical attributes. A cross-sectional study was conducted on 123 attendees aged 60 years and above at Pusat Perubatan Primer Universiti Kebangsaan Malaysia. Sleep quality and psychological distress were assessed using the validated Malay versions of Pittsburgh sleep quality index (PSQI) and Hamilton anxiety depression scale (HADS) respectively. Information on medical comorbidities and medications were obtained from the participants, their doctors and medical notes. Almost half of the patients experienced poor sleep quality (47.2%) which was significantly associated with older mean age (69.5 ±4.55). There was no statistical significance between sleep quality and other sociodemographic characteristics (gender, ethnicity and living arrangement). Most patients described their sleep quality as subjectively generally “fairly good” (69.1%) despite PSQI scores indicating poor sleep quality. A majority of the patients (59.3%) were on follow-up for 3 or more medical illnesses, with heart disease as the only medical comorbidity significantly associated with poor sleep quality. Most of them also complained of only “mild difficulty” with their sleep. Among the 7 sleep components of PSQI, “sleep disturbance” was the most frequent experience. Most experienced mild sleep disturbance (87.8%) and usage of hypnotic agents was low (6.5%). Only 23.6% of patients had significant psychological distress (HADS scores ≥ 8), with positive correlation with sleep quality.
Sleep ; Polysomnography

Simulated/ standardized patients (SPs) have become one of the significant components in today’s medical education and students’ assessment. Some differences exist in the training method of SPs for psychiatry examinations compared to other medical disciplines. This brief report highlights the challenges encountered in the training process and methods to overcome those challenges. A wellstructured, intensive training remains as one of the most important factors in ensuring standardization of SPs for psychiatric examinations.
Education, Medical ; Psychiatry

Introduction: This study aimed to identify dietary patterns (DPs) and their association with successful aging (SA). Methods: A comparative cross-sectional study was conducted among 579 elderly subjects recruited from four states in Malaysia through a multistage random sampling method. SA was defined as having no chronic illnesses, no functional limitation, normal global function, no depression, a good quality of life and good self-perceived health. Information on dietary intake was obtained using a diet history questionnaire. Cognitive functions were assessed using the Mini Mental State Examination (MMSE), depressive symptoms using Geriatric Depression Score-15 items (GDS-15) and a question regarding their perceived health and quality of life. Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) questionnaires were used to determine functional status. DPs were obtained using the principal component analysis (PCA) approach. An ordinal logistic regression model was used to examine associations between DP scores and SA. Results: Five DPs were identified namely ‘sweet foods-beverages’, ‘meat-vegetablesrice and noodles’, ‘local snacks-fish and seafood-high salt foods’, ‘fruits-legumes’, and ‘tropical fruits-oats’. A higher score for ‘tropical fruits-oats’ DP was associated with SA [Adjusted OR=1.59 (95% CI: 1.08-2.32)]. However, the association diminished when the model was adjusted for education level. Further analysis indicated that this DP increased the chance of SA among those with secondary education and above [Adjusted OR=2.43 (95% CI: 1.09–5.42)]. Conclusion: Tropical fruits-oats’ DP is associated with SA among elderly with secondary education and above. There is a need to investigate DPs among those with lower education.