Asthma is a chronic inflammatory airway disease, for which the cornerstone of asthma therapy is inhaled corticosteroids. however, long term clinical outcomes are variable, and not all patients respond optimally to corticosteroids. Underpinning this observation is that asthma is a heterogeneous disease consisting of phenotypes that are driven by different inflammatory pathways. In this article, we will discuss the different inflammatory mechanisms of asthma to better define patient characteristics and help improve patient outcomes with newer specific-targeted asthma therapies.

Asthma is a chronic inflammatory airway disease, for which the cornerstone of asthma therapy is inhaled corticosteroids. however, long term clinical outcomes are variable, and not all patients respond optimally to corticosteroids. Underpinning this observation is that asthma is a heterogeneous disease consisting of phenotypes that are driven by different inflammatory pathways. In this article, we will discuss the different inflammatory mechanisms of asthma to better define patient characteristics and help improve patient outcomes with newer specific-targeted asthma therapies.

The Mental Capacity Act (MCA) addresses the need to act on behalf of persons who are unable to make decisions for themselves.One of the consequences of Singapore’s rapidly aging population is the rise in the number of patients suffering from stroke and age-related neuro-degenerative diseases. As their cognitive function deteriorates, they also lose their ability to make independent decisions, and this makes them at risk of potentially detrimental decisions made by them or others. Conflicts and uncertainty may come about because of a lack of clarity concerning the wishes of the individual with mental incapacity. There is a growing concern amongst individuals that, on losing their mental capacity, they also lose their right to determine their preferences to choose. The MCA has mechanisms in place to address such issues.The Singapore Family Physician first published an article on the Mental Capacity Act in 2009, and its lessons and messages hold for family physicians today. This article further updates on two provisions of the MCA:1.Lasting Power of Attorney (LPA) Certification2.Court-appointed Deputy Application for PatientsThe former allows for persons who are cognitively intact to appoint one or more persons to act on their behalf should they lose their mental capacity in the future.Should a person not have made an LPA before losing mental capacity, a deputy is appointed by the court to make certain decisions on their behalf. A deputy can be an individual or a licensed trust company under the Trust Companies Act (Cap.336).This paper will explore the processes involved in certifying the LPA as well as the court-appointed deputies.

Sleep disturbance is common in the elderly and is frequently undiagnosed. It has been estimated that 75 percent of adults >65 years of age has sleep disturbance and 30 percent of themhas insomnia. The classification of insomnia has less significance in the older adults as the subtypes demonstrate significantoverlap and usually treatment of the underlying disorder doesnot solve the problem or cure it. The elderly has multiplecomorbidities and poly pharmacy with a myriad of cause forinsomnia. A comprehensive medical and psychiatric historytogether with a complete physical examination and mentalstate examination should be done in the evaluation of the older patient. Behavioural therapy with sleep hygiene educationshould be the initial treatment together with the treatmentof the contributing physical and psychiatric conditions.Referral to an expert for cognitive behavioural therapy ormulticomponent therapy may be necessary if the initial therapy failed to produce any improvement. If medications are neededit can be combined with behavioural therapy. Medication usedshould be the lowest effective dose and prescribed for short-term use of not more than four weeks. Medications used needto be discontinued gradually and one needs to be mindfulof rebound insomnia upon withdrawal. Whenever possible,it will be ideal to avoid benzodiazepines and other sedativehypnotics as first choice for insomnia. Over the counter sleepaids which usually contain antihistamines may not be goodchoices as they carry significant risk of adverse events and druginteractions. Currently the safest medications for use in theelderly includes the Z-drugs (zolpidem, zopiclone), melatoninand low dose tricyclic antidepressant Doxepin.

A large proportion of older adults visit the family physician’s practice within the community. It is imperative for the family physician to be familiar not just with the common geriatric syndromes but also to be aware of modern geriatric giants like sarcopenia and frailty as they are associated with adverse outcomes that can significantly affect the older adult’s function. They can be readily identified with simple screening tools like SARC-F and FRAIL scale. Management will consist of multifactorial interventions, focusing especially on resistance exercises and protein supplementation

Parkinson’s disease (PD) is the second most common neurodegenerative disorder globally and its prevalence in Singapore is expected to increase exponentially with our ageing population. Diagnostic and management issues unique to the elderly population will be discussed broadly in this topic review.

Introduction. Stroke continues to be a major cause of mortality and disability. Besides having residual motor, sensory, or language deficits, there is a need to identify cognitive and mood related issues as well.Stroke recovery may be best defined as improvement across a variety of outcomes, beginning with biological and neurologic changes that manifest as improvement in performance and activity based behavioural measures. Alternatively, the broad definition of stroke rehabilitation is: any aspect of stroke care that aims to reduce disability and promote participation in activities of daily living. The objectives of this process are: to prevent deterioration of function; improve function; achieve the highest possible level of independence within the limits of the persistent stroke impairments. The three approaches of rehabilitation are that of restoration, compensation and modification. Four phases (hyperacute, acute, subacute and community reintegration phase) are recognized during stroke rehabilitation, although there is no consensus for the duration of each phase. Specific conditions such as post-stroke shoulder pain, depression and spasticity should be identified and appropriate treatment rendered to improve function and quality of life for the patient.Conclusion. Post-stroke patients are increasingly likely to survive and progress to the chronic phase of rehabilitation. It is useful to understand the difference between stroke recovery and rehabilitation and to be aware of pathologies that may impede rehabilitation

Vaccination has reduced the disease burden of infectious disease since it was invented. Each person has his or her own unique vaccination needs during the various stages of one’s life. What each one needs is determined by one’s health, age, lifestyle and occupation at that time. Strategically, the Centre for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) introduced a simple HALO2 approach to help physicians customise vaccinations for the public with the circumstances and needs of the public in mind. With the HALO approach, the public is able to discuss with their personal family physician or general practitioner and receive the relevant vaccines to prevent diseases and maintain health.

Influenza is a highly contagious viral illness characterized by fever, cough, headache and myalgia. The influenza virus is a segmented ribonucleic acid (RNA) virus that can infect both humans and animals, and the capacity for reassortment when multiple viruses infect the same cell has led – and will continue to lead – to the development of novel pandemic influenza A viruses. The disease is generally self-limiting, although complications and deaths can occur, particularly in children < two years of age, adults >65 years of age, pregnant women, and immunosuppressed individuals. Specific antiviral therapy is available, including oseltamivir in Singapore, and is recommended for severe disease as well as those with higher likelihood for developing complications from influenza. In addition to hand hygiene and respiratory etiquette, antiviral prophylaxis may reduce the impact and burden of influenza in household and institutional settings. However, the primary means for preventing influenza is via annual vaccination in those above the age of two years. The influenza vaccine, while having variable efficacy depending on antigenic matching with circulating viruses each year, is safe and cost-effective at the population level.

Pertussis is mainly thought to be a disease affecting young children, but it can also affect adults and the elderly. While vaccination has largely reduced the incidence of pertussis compared to the pre-vaccine era, there has been an upswing in the incidence, and outbreaks continue to occur.