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August 6, 2016

Experts for increased interaction between psychiatry and neurology


August 6, 2016



The Institute of Psychiatry here at Benazir Bhutto Hospital in town hosted a lecture on ‘Dementia: An Overview & Recent Advances in Management’ with a special emphasise on the need for an increased interaction between psychiatry and neurology.

The guest speaker was Consultant Neurologist at Shifa International Hospital Professor Arsalan Ahmad was the guest speaker at the lecture that was attended by psychologists and residents and consultants from both neurology and psychiatry departments.

Head of Institute of Psychiatry Professor Fareed A. Minhas setting the stage for the guest speaker said it is tradition of the Institute to host guest lectures on recent advances in the field of research. He alluded towards the overlap between psychiatry and neurology; many psychiatric patients present to neurologists and vice versa. Invariably, he said a good evaluation would result in unveiling problems that require both neurological and psychiatric attentions.

He shared with the audience his satisfaction with the residents from Shifa neurology department especially their professionalism and knowledge base when they rotate at the Institute. He also appreciated Professor Arsalan’s department for providing the psychiatry residents from BBH with an enlightening experience when they rotate there. He lamented the dearth of neurologists in our region manifested by the fact that Rawalpindi Medical College does not have any neurologists.

Turning to the importance of the topic, Professor Minhas said that within the next few years, genetics will play a major role in psychiatry and neurology. This lecture, he emphasised, is an ideal opportunity for you to be introduced to the nuts and bolts thereof. Sadly, he said, we have precious little local research in this area.

As health care gets better, people survive to an older age and thus dementias increase. The disability associated is severe. The brunt of it is dealt by Neurology and so Professor Arsalan is the best man to update us on the topic, said Professor Minhas.

Professor Arsalan then began his presentation by stressing on the need for an increased interaction between psychiatry and neurology. He reminded everyone of the joint conferences between neurology and psychiatry. These have sadly dwindled over the years due to increase in numbers of consultants and the patient burden, he said.

He reminded the audience that dementia is a progressive deterioration in cognitive abilities with Alzheimer's being its most common type. It is a disease of the elderly and its risk doubles with every five years after 65 years of age. He alluded to the prevalence of the illness being 4.8 million in 2010 and how it would double to 9.5 million people by 2030, and to 18 million in another 20 years.

For the lack of local data, he shared the prevalence rates in adjoining countries and using their estimates said that between 160,000 – 240,000 people may be suffering from this illness in Pakistan. This, he said, would increase as life expectancy will increase.

Talking of clinical features of the illness, he said in normal aging, people complain of forgetting but if you ask them to focus they may be able to remember. In dementia, family will complain that the patient is forgetful. Instrumental activities deteriorate in dementia, he said.

He emphasised on the importance of clinical and physical examination and psychological tools like the Mini Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) tool to diagnose a patient. He said that the interpretation of these tools should take education level, skills, language and sensory impairments in to consideration.

He asked the attendees to always look for pseudo dementia; rule out other psychiatric illnesses to ensure appropriate patient care and referral to psychiatrists wherever necessary. Equally important, he said is to rule out medical causes; of them hypothyroidism and vitamin B-12 being the most common and treatable causes especially in younger individuals.

He also highlighted the acute onset and underlying organic illness that distinguishes delirium from dementia. He also mentioned the importance of ruling out immune encephalitis.

Professor Arsalan also referred to drugs like antihistamines and digoxin etc. as a cause of memory impairment, and so that these too should be ruled out. He spoke about the importance of diagnostic imaging to rule out treatable causes.

He then took the discussion towards management. The most important point, he said, is that pharmacological treatment is mainly symptomatic and no disease modifying agent exists. It is important to inform the patients and their attendants of the realistic expectations from these drugs and to keep in mind their affordability while prescribing. He discussed the doses and side-effects of drugs.

Speaking of the non-pharmacological interventions for prevention, he referred to many studies that showed no side effect. One particular study entitled FINGER, showed that multi-domain approach (including dietary habits, active lifestyle, novelty seeking, etc.) showed the best preventive effect, he said.

He also alluded to the patient safety issues that should be addressed; since the patients are cognitively compromised they may get lost or harm themselves or others, so appropriate preventive measures need to be taken. Patients may require 24/7 home help, arm bands for ID, and even GPS monitoring. The patients diagnosed early may need to be told to prepare their will or any other advanced directives they would want to leave behind, said Professor Arsalan.

In the questions and answers session, Dr. Asad Nizami inquired as to what the people who have a family history of the illness should do. Professor Arsalan acknowledged that it is a very grave issue. He spoke about a patient who had dementia in her fifties and how her two children are living with the dread of getting this illness. One of the siblings in her 40’s says that she is only planning for a life till 50 years of age and her brother is continuously engaging in novel activities in order to prevent himself from acquiring the illness. At this point Professor Arsalan also shared his observation that he had not found a single ‘hafiz’ in his dementia registry and hypothesised that it may be a possible preventive measure.




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