Pharmacotherapeutic aspects of dementia care in Malta

Dementia is the most common neurodegenerative disorder of old age affecting one percent of the local general population. It is a major predictor of morbidity and mortality in the elderly, adding a significant burden on health and social care systems across Europe. The financial impact of caring for individuals with dementia is considerable and progressive loss of cognitive function does not only pose challenges to the patients but also adds significant strain on the well-being of caregivers and family members. Although no cure is available, disease progression can be delayed by early intervention and by the use of pharmacotherapeutic agents that interfere with central neurotransmitter systems involved in cognitive processes. This review presents current trends in pharmacotherapeutic intervention in dementia care together with caregiver perceptions on treatment expectations in Malta.peer-reviewe

Assessment of people with memory symptoms

Dementia is a term that refers to those disorders of the brain that result in progressive impairment of brain functions such as memory, language, judgement and thinking. Dementia affects the ability of the person to function and creates difficulties in performing familiar and previously known tasks, eventually even impairing the person's ability to take care of oneself. The commonest cause of dementia is Alzheimer's Disease, accounting for some 50 - 60% of all cases of dementia. Other common conditions resulting in dementia are Vascular Dementia and Lewy Body Disease. There is currently no definite cure from dementia, but treatment is now available that may help some of the symptoms and may help regain some abilities, delaying the need for nursing home care.peer-reviewe

Management of behavioural and psychological symptoms of dementia

Recently, there have been many publications expressing concern towards the inappropriate and excessive use of neuroleptic medication in dementia. In 2004, a safety message was issued by the Committee on Safety of Medicines of the United Kingdom concerning the use of atypical antipsychotics in patients with behavioural and psychiatric symptoms of dementia. This alert followed the analysis of manufacturer data which showed an increased risk of cerebrovascular adverse events with risperidone and olanzapine. The magnitude of increased risk in the studies analysed was in the region of three times. It has been recommended that these drugs are prescribed only following a careful assessment of benefits and risks, are used in the lowest possible dose and for a specified period of time. Although the other 'typical' neuroleptic drugs are commonly prescribed to treat behavioural and psychiatric symptoms in dementia, there is little evidence-base to support this practice. Typical antipsychotic drugs are known only to be modestly effective and can have potentially serious side-effects especially in older adults. There have been many studies on the overuse of antipsychotic medication, especially in people with dementia and those living in nursing homes. These drugs are associated with extrapyramidal side effects, increased risk of falling, excessive sedation and accelerated cognitive decline. Several trials have also shown that these drugs can be safely discontinued in many of these situations.peer-reviewe

A review of the aetiology and management of vocal behaviour in dementia

Vocal behaviour is a common form of agitation displayed by people with dementia. It refers to excessive screaming, abusive language, moaning, perseveration, and repetitive and inappropriate requests. The authors provide a literature review on this form of challenging behaviour, focusing on the aetiological factors and the available treatment options. Emphasis is put on a biopsychosocial approach. The aim of this article is to increase awareness of the condition in elderly nursing residences and hospitals, and to encourage best evidence-based practice.peer-reviewe

Estimated prevalence of dementia in the Maltese Islands

Dementia is a serious, common, world-wide neurodegenerative disease associated with severe loss of cortical brain. It is a major predictor of morbidity and mortality in the elderly costing the health services more than cardiovascular disease and cancer put together. Recent studies have also suggested that the global prevalence of dementia would double every twenty years and should reach approximately 82 million cases by the year 2040. Using EURODEM data, we report that the estimated number of individuals with dementia in the Maltese islands is 4,072. This figure is expected to almost double by the year 2035. We discuss the implications of the forecast increase in the number of people with dementia for Malta's health services and society.peer-reviewe

The outcome of elderly patients following removal of indwelling urinary catheter

The objectives of this study were to examine the documented indications for the insertion of the indwelling urinary catheter in elderly patients before admission to Zammit Clapp Hospital, St. Julians and St Vincent de Paule Residence, Luqa and to study the outcome after attempting removal of the indwelling urinary catheter. 64 patients from Zammit Clapp Hospital and 61 patients from St. Vincent de Paule Residence were studied. In 34 patients (24%), no clear reason for catheterisation prior to admission could be identified. In 46 patients (32 %) catheterisation was performed for severe uncontrollable incontinence. In all, 66 patients had their indwelling urinary catheter removed at some stage. Of these a total of 49 patients were continent 15 days after the removal of the catheter, 33 patients were still continent after 3 months and 29 patients remained continent after one year. With regards’ to continence rate, a poorer outcome was noted in patients with a mental score of less than 5/10, when compared to patients with a mental score of more than 5/10. Continence rates were better in patients from Zammit Clapp Hospital than in patients from St. Vincent de Paule residence. In conclusion, attempts should be made to use long term indwelling urinary catheterisation only if other measures fail. This can be achieved by proper multi-disciplinary team assessment and education of the patient or his carers. Full support from social services and provision and advice about the use of continence aids is necessary.peer-reviewe

The Malta Dementia Society

The patterns of illness that accompany old age have profound social and economic consequences for society as a whole and for healthcare systems in particular. Dementia is a serious, common, and rapidly growing world-wide neurological condition associated with increased healthcare utilisation. It is the major predictor of morbidity and mortality in the elderly.peer-reviewe

Glycosylated haemoglobin (HbA1c) and cortisol levels on admission to intensive care as predictors of outcome

Objective: To evaluate the predictive value of glycosylated haemoglobin and cortisol on admission, in critical care patients. Design: Prospective, observational, single centre study. Setting: 14 bedded Intensive care unit of a tertiary-level university hospital. Patients: 124 consecutive emergency medical and surgical patients. Methods: Data collected on admission included patient demographics, medical history, medication, diagnosis, type of nutrition, TISS28 score, serum blood glucose, Glycosylated haemoglobin (HbA1c), cortisol, mean arterial blood pressure, and the use of inotropes in the first 24hrs. Daily baseline tests included complete blood count, urea and electrolytes, creatinine, twice weekly liver function tests. The primary outcome measure was intensive care unit mortality. Secondary outcome measures were ITU stay, days of ventilation, peak urea, peak creatinine, lowest platelet count, peak bilirubin, lowest Pa/FiO2, and the number of transfusions. Measurements and results: 124 patients (mean age 56.2 years SD 23.2) were included. Regression analysis was used to identify any potential predictors of outcome: HbA1c levels on admission were not found to be significantly associated with mortality (p=0.51), or any other secondary endpoints listed above. However, subgroup analysis revealed a predictive role of HbA1c with regards to length of ITU stay (p= 0.01) and number of days of ventilation (p=0.007) in those patients with a history of diabetes. Glucose level on admission emerged as an independent marker of mortality (p=0.009). Conclusions: This study suggests that HbA1c may not be a predictor of outcome in the general ITU population but may be of predictive value in diabetic ITU patients. On the other hand, blood glucose levels on admission emerged as a predictor of mortality, whilst no association was found between HbA1c and cortisol levels on admission.peer-reviewe

Presentation and management of diabetic ketoacidosis in adults in Malta

Aim: The aim of this audit was to assess adherence to local guideline in the management of Diabetic Ketoacidosis (DKA). Method: Patients admitted with DKA between April 2013 and March 2015 were identified and data was retrospectively collected from patients’ confidential files and Isoft®. Data collected included initial parameters recorded and biochemical investigations taken (initial and subsequent assessment of pH, HCO3-, blood glucose, potassium levels and urinary ketones), insulin regime started and intravenous fluid administered. Results: During the established time period 40 cases of DKA were identified in 18 patients. Median age was 33 years with a female preponderance of 60%. Six patients had newly diagnosed diabetes mellitus while 8 patients had more than one admission of DKA. All cases had capillary blood glucose monitoring (BGM) and/or venous random blood (plasma) glucose (RBG) checked and pH and HCO3- recorded on admission. 0.9% sodium chloride was the intravenous fluid started in all cases (as recommended by the guideline) and a median of 6.75L was prescribed during the first 24 hours. The median time spent on intravenous insulin infusion was 42.7 hours while the median time to pH >7.30, HCO3- >15mmol/L and negligible urinary ketones were 6.88, 12.83 and 34.5 hours respectively. Subcutaneous insulin was started at a median time of 48.21 hours from initiation of DKA protocol. Conclusion: This audit showed good adherence to local guideline. The great discrepancy between the time to pH >7.3 and the time to negligible urinary ketones highlights the need to introduce tools to measure systemic ketone production in the management of DKA with an update in the current local clinical practice guideline.peer-reviewe