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Behabioural and Psychological SYMPTOMS OF DEMENTIA ASSESSMENT AND MANAGEMENT

The Singapore Family Physician.2019;45(3):6-11.

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.

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Behabioural and Psychological SYMPTOMS OF DEMENTIA ASSESSMENT AND MANAGEMENT

Vanessa wai ling Mok

The Singapore Family Physician.2019;45(3):6-11.

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.

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MENTAL CAPACITY ASSESSMENT (AN UPDATE): LASTING POWER OF ATTORNEY CERTIFICATION

tze lee tan

The Singapore Family Physician.2019;45(3):11-17.

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.

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INSOMNIA IN THE ELDERLY: EVALUATION AND MANAGEMENT

Matthew joo ming ng ; Beng Yeong ng

The Singapore Family Physician.2019;45(3):19-25.

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.

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MODERN GERIATRIC GIANTS: SARCOPENIA AND FRAILTY

Joanne Ee Chia Kua

The Singapore Family Physician.2019;45(3):14-17.

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

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PARKINSON’S DISEASE IN THE ELDERLY

Shermyn Neo ; Eng King Tan

The Singapore Family Physician.2019;45(3):30-33.

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.

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STROKE REHABILITATION PRINCIPLES

Geoffrey Samuel Sithamparapillai

The Singapore Family Physician.2019;45(3):34-37.

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

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Asthma Action Plan for Adults

Jessica Lishan Quah ; Yi Hern Tan ; Tunn Ren Tay

The Singapore Family Physician.2018;44(4):14-19.

Asthma action plan (AAP) is an essential component of asthma education and self-management. AAPs provide patients with instructions on how to recognise loss of asthma control and the appropriate treatment steps. The use of AAP improves asthma-related quality of life and reduces the risk of asthma exacerbation. Despite its benefits, utilisation of AAP is disappointingly low both locally and worldwide. This review highlights the importance of AAP as part of an asthma care plan and provides practical information on the prescription of AAPs. We conclude by identifying possible barriers to AAP implementation and how these may be overcome.

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Dynamic Interactions in the Primary Care Consultation, and an Introduction to Balint Groups

Eugene Wuan ; Andre Teck Sng Tay ; Andrew Lai Huat Peh

The Singapore Family Physician.2018;44(4):32-35.

Physicians in the primary care setting, such as General Practitioners and doctors working in polyclinics, will encounter patients with varying expectations of the consultation process, especially with regards to their emotional needs. These interactions, shaped by transference and counter-transference, will often induce varying emotional reactions in the physicians, both positive and negative. Understanding the dynamics which drive these interactions, and reflecting upon the physician's own emotional responses, can often lead to a more holistic appreciation of the patient and the therapeutic relationship, and consequently in improved patient care, and enhanced satisfaction for both the patient and physician. This article highlights the above dynamic interactions, and introduces the Balint Group, a platform whereby such themes and processes can be further explored. The processes of the Balint Group, and its benefit for attending members, are discussed.

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House calls in Singapore – A Qualitative Study

Ling Ling Soh ; Gerald Choon-Huat Koh ; Rakhi Mittal

The Singapore Family Physician.2018;44(4):35-42.

Background Historically, physicians routinely delivered medical care to sick patients in patients' homes. While house calls accounted for 40% of all doctor-patient encounters In the 1940s, the rate has since dwindled to less than 1%. Based on some studies done overseas, the reasons for the unpopularity of house calls were the lack of time and unsatisfactory remuneration. The aim of this study was to explore the attitudes of general practitioners (GPs) currently practicing in Singapore towards house calls. Design A qualitative study using phenomenological methodology was done by conducting one-to-one in-depth interviews with 12 GPs. Results All the GPs interviewed were aware of the benefits of house calls in the healthcare scene of Singapore. The commonest barrier was concern about the limitations perceived to be present during a house call and their possible medicolegal implications. GPs also struggled with charging appropriately for house calls and found them disruptive to their practices. Conclusion: The study shows that GPs recognize the value of making house calls but at the same time struggle with perceived limitations in the home setting as well as remuneration issues.

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