Publications by authors named "Samantha M Loi"

37 Publications

Psychiatric and cognitive characteristics of older adults admitted to a Video-EEG monitoring (VEM) unit.

Epilepsy Behav 2021 Jul 9;120:107987. Epub 2021 May 9.

Department of Medicine (RMH), The University of Melbourne, Australia; Department of Neurology, Royal Melbourne Hospital, Parkville, Australia; Melbourne School of Psychological Sciences, The University of Melbourne, Australia.

Objective: To compare the clinical, psychiatric, and cognitive characteristics of older with younger patients presenting to a video-EEG monitoring (VEM) unit.

Method: This was a retrospective case-control study involving patients admitted for VEM over a two-year period (from April 2018 to April 2020) at two comprehensive epilepsy units. Patients were categorized into an older (≥60 years) and a younger (<60 years) group. Younger patients were individually matched to older adults to form a matched younger group. Diagnosis was determined by a consensus opinion of epileptologists, neurologists, and neuropsychiatrists. The main diagnostic categories were epilepsy, psychogenic nonepileptic seizures (PNES), and 'other' diagnosis (non-diagnostic and other nonepileptic diagnoses). Clinical psychiatric diagnoses were obtained from neuropsychiatric reports. Objective cognitive function was measured with the Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG). Subjective cognitive function was assessed using the Quality of Life in Epilepsy Inventory-89 (QOLIE-89) cognitive subscales.

Results: Five-hundred and thirty three patients (71 older, 462 younger) aged 16-91 years were admitted to the VEM unit during the study period. There was a diagnosis of focal epilepsy in 55% of the older group and 48% of the younger group, generalized epilepsy in 3% of the older group and 10% of the younger group, and 'other' in 32% of the older group and 19% of the younger group. Ten percent (2 males and 5 females) of the older group were diagnosed with PNES compared to 22% of the younger group (p = 0.016). A depressive disorder was diagnosed in 34% of the older group and 24% of the younger group (p = 0.20). An anxiety disorder was diagnosed in 15% of the older group and 25% of the younger group (p = 0.15). Mild neurocognitive disorder was more common in the older group (34%) compared to the matched younger group (34% vs 3%, p < 0.001). The older group had lower mean NUCOG scores compared to the matched younger group (79.49 vs 87.73, p = <0.001). There was no evidence for a relationship between mean NUCOG score and overall subjective cognitive difficulties for the older group (r = 0.03, p = 0.83). Among older adults, those diagnosed with PNES had more experiences of childhood trauma. Measures of dissociation, depression, or general anxiety did not differ between PNES and non-PNES diagnoses in the older group.

Conclusion: Psychiatric comorbidities are common among older adults admitted for VEM. The psychological impact of epilepsy and risk factors for PNES seen in younger patients are also applicable in the older group. The older group demonstrated more cognitive impairments than the younger group, although these were usually unrecognized by individuals. Older adults admitted to VEM will benefit from psychiatric and neuropsychological input to ensure a comprehensive care approach to evaluation and management.
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http://dx.doi.org/10.1016/j.yebeh.2021.107987DOI Listing
July 2021

Predictors of New-Onset Epilepsy in People With Younger-Onset Neurocognitive Disorders.

Front Aging Neurosci 2021 16;13:637260. Epub 2021 Mar 16.

Department of Neuroscience, The Central Clinical School, Monash University, Melbourne, VIC, Australia.

People with neurocognitive disorders (NCDs) have an increased risk of epilepsy. However, most studies investigating the risk of seizures in people with NCDs are limited to those with Alzheimer's disease (AD) and vascular dementia (VD), and those who developed dementia after age 65 years. A knowledge gap exists regarding factors associated with development of epilepsy in people with younger-onset NCD, and those with non-AD and non-VD dementia subtypes. In this study, we aimed to identify the factors associated with the development of epilepsy in people with younger-onset NCDs of varied etiologies, the majority of whom had symptom onset prior to age 65 years. This was a retrospective study reviewing the medical records of consecutive people admitted with cognitive impairment to a tertiary neuropsychiatry unit between 1 January 2004 and 30 April 2019. People diagnosed with primary NCDs were included in the analysis. The prevalence and characteristics of epilepsy were described. The factors associated with developing epilepsy were identified in a binary logistic regression model. A total of 427 people were included. One hundred fourteen had Alzheimer's disease, 104 frontotemporal dementia, 51 vascular dementia, 69 movement disorder-associated dementia, and 89 unspecified NCD. The median age on admission was 59 years (range 33-86) and 75.2% ( = 321/427) had young-onset NCD with onset before 65 years of age. 40/427 (9.4%) people had epilepsy, and epilepsy onset clustered between 2 years before and 6 years after the onset of cognitive decline in 80% ( = 32/40). The most frequent seizure type was focal to bilateral tonic-clonic seizure (35%, = 14/40). Most of the people (94.7%, = 36/38) achieved seizure freedom with one or two antiseizure medications. People with unspecified NCD (compared to frontotemporal dementia and movement disorder-associated dementia, age of onset of NCDs ≤50 years, and current smoking status were independently associated with higher risk of developing epilepsy. Epilepsy is common in people with younger-onset NCDs, and a high index of suspicion is warranted particularly for those with unspecified subtype and smoking status. Smoking reduction or cessation should be further investigated as a potentially modifiable factor for risk reduction.
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http://dx.doi.org/10.3389/fnagi.2021.637260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8010684PMC
March 2021

Odor Identification Testing Can Assist in the Clinical Distinction Between Psychiatric Disorders and Neurological/Neurodegenerative Disorders.

Alzheimer Dis Assoc Disord 2021 Mar 23. Epub 2021 Mar 23.

1st Department of Neurology, Eginition Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece Department of Neuropsychiatry Department of Neurology, Royal Melbourne Hospital Melbourne Neuropsychiatry Centre, University of Melbourne and North Western Mental Health, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne Florey Institute of Neuroscience and Mental Health Department of Psychiatry, University of Melbourne, Parkville, Vic., Australia.

Background/objectives: The aim was to identify whether performance on olfactory identification can distinguish neurological/neurodegenerative disorders (NNDs) from primary psychiatric disorders (PPDs).

Methods: This is a cross-sectional retrospective study of inpatients assessed in Neuropsychiatry, Royal Melbourne Hospital. Data extracted from the admission records included: demographics, tobacco use, medical comorbidities, cognitive function using the Neuropsychiatry Unit Cognitive Assessment Tool (NUCOG), and odor identification using the Sniffin' Sticks Screening 12 test. The final diagnosis for patients was informed by established diagnostic criteria.

Results: A total 121 patients were included. Eighty-eight patients (73%) were diagnosed with neurological or neurodegenerative disease, including Alzheimers dementia, frontotemporal dementia, Lewy body parkinsonian-related dementias (Parkinson disease, multiple system atrophy, dementia with Lewy bodies) and other neurological causes of dementia; 33 patients (27%) were diagnosed with PPDs (including mood and psychotic disorders). Patients who scored ≤8 on the Sniffin' Sticks Screening 12 test were more likely to have NND than PPD, even after adjustment for age, sex and tobacco use (P=0.009, adjusted odds ratios=3.85, 95% confidence interval=1.40-10.62). Receiver operating characteristic curve analyses demonstrated that a score of ≤8 differentiated NND from PPD with sensitivity of 57% and specificity of 73% (receiver operating characteristic area under the curve of 0.67, P=0.004).

Conclusions: Patients with neuropsychiatric difficulties who score 8 or less on Sniffin' Sticks are more likely to have a neurodegenerative illness. A cut-off score of 8 is potentially a "red flag" for clinicians faced with the diagnostic question of PPD versus NND.
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http://dx.doi.org/10.1097/WAD.0000000000000441DOI Listing
March 2021

Network Analysis of Symptom Comorbidity in Schizophrenia: Relationship to Illness Course and Brain White Matter Microstructure.

Schizophr Bull 2021 Mar 8. Epub 2021 Mar 8.

Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Carlton South, Victoria, Australia.

Introduction: Recent network-based analyses suggest that schizophrenia symptoms are intricately connected and interdependent, such that central symptoms can activate adjacent symptoms and increase global symptom burden. Here, we sought to identify key clinical and neurobiological factors that relate to symptom organization in established schizophrenia.

Methods: A symptom comorbidity network was mapped for a broad constellation of symptoms measured in 642 individuals with a schizophrenia-spectrum disorder. Centrality analyses were used to identify hub symptoms. The extent to which each patient's symptoms formed clusters in the comorbidity network was quantified with cluster analysis and used to predict (1) clinical features, including illness duration and psychosis (positive symptom) severity and (2) brain white matter microstructure, indexed by the fractional anisotropy (FA), in a subset (n = 296) of individuals with diffusion-weighted imaging (DWI) data.

Results: Global functioning, substance use, and blunted affect were the most central symptoms within the symptom comorbidity network. Symptom profiles for some patients formed highly interconnected clusters, whereas other patients displayed unrelated and disconnected symptoms. Stronger clustering among an individual's symptoms was significantly associated with shorter illness duration (t = 2.7; P = .0074), greater psychosis severity (ie, positive symptoms expression) (t = -5.5; P < 0.0001) and lower fractional anisotropy in fibers traversing the cortico-cerebellar-thalamic-cortical circuit (r = .59, P < 0.05).

Conclusion: Symptom network structure varies over the course of schizophrenia: symptom interactions weaken with increasing illness duration and strengthen during periods of high positive symptom expression. Reduced white matter coherence relates to stronger symptom clustering, and thus, may underlie symptom cascades and global symptomatic burden in individuals with schizophrenia.
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http://dx.doi.org/10.1093/schbul/sbab015DOI Listing
March 2021

Systematic Review: Quantitative Susceptibility Mapping (QSM) of Brain Iron Profile in Neurodegenerative Diseases.

Front Neurosci 2021 18;15:618435. Epub 2021 Feb 18.

Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne and Melbourne Health, Carlton South, VIC, Australia.

Iron has been increasingly implicated in the pathology of neurodegenerative diseases. In the past decade, development of the new magnetic resonance imaging technique, quantitative susceptibility mapping (QSM), has enabled for the more comprehensive investigation of iron distribution in the brain. The aim of this systematic review was to provide a synthesis of the findings from existing QSM studies in neurodegenerative diseases. We identified 80 records by searching MEDLINE, Embase, Scopus, and PsycInfo databases. The disorders investigated in these studies included Alzheimer's disease, Parkinson's disease, amyotrophic lateral sclerosis, Wilson's disease, Huntington's disease, Friedreich's ataxia, spinocerebellar ataxia, Fabry disease, myotonic dystrophy, pantothenate-kinase-associated neurodegeneration, and mitochondrial membrane protein-associated neurodegeneration. As a general pattern, QSM revealed increased magnetic susceptibility (suggestive of increased iron content) in the brain regions associated with the pathology of each disorder, such as the amygdala and caudate nucleus in Alzheimer's disease, the substantia nigra in Parkinson's disease, motor cortex in amyotrophic lateral sclerosis, basal ganglia in Huntington's disease, and cerebellar dentate nucleus in Friedreich's ataxia. Furthermore, the increased magnetic susceptibility correlated with disease duration and severity of clinical features in some disorders. Although the number of studies is still limited in most of the neurodegenerative diseases, the existing evidence suggests that QSM can be a promising tool in the investigation of neurodegeneration.
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http://dx.doi.org/10.3389/fnins.2021.618435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7930077PMC
February 2021

A description of the components of a specialist younger-onset dementia service: a potential model for a dementia-specific service for younger people.

Australas Psychiatry 2021 Feb 24:1039856221992643. Epub 2021 Feb 24.

Neuropsychiatry, NorthWestern Mental Health, Royal Melbourne Hospital, Parkville, Australia.

Objectives: This narrative paper describes the influences behind the development of, and key components of a specialist younger-onset dementia service located in metropolitan Victoria, Australia.

Conclusion: The Melbourne Young-Onset Dementia Service was established in 2013 and provides diagnosis and ongoing care for people with younger-onset dementia and their families, through collaboration with other medical units, allied health and community services. It is potentially a model for other younger-onset dementia services nationally and internationally.
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http://dx.doi.org/10.1177/1039856221992643DOI Listing
February 2021

Development and validation of a screening questionnaire for psychogenic nonepileptic seizures.

Epilepsy Behav 2020 11 28;112:107482. Epub 2020 Sep 28.

The Epilepsy Unit, Alfred Health, Melbourne, Australia; Department of Neurology, The Royal Melbourne Hospital, Melbourne, Australia; Clinical Outcomes Research Unit (CORe), Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Australia; Department of Medicine (The Royal Melbourne Hospital), The University of Melbourne, Australia; Melbourne School of Psychological Sciences, The University of Melbourne, Australia.

Objective: Epilepsy and psychogenic nonepileptic seizures (PNES) are serious conditions, associated with substantial morbidity and mortality. Although prompt diagnosis is essential, these conditions are frequently misdiagnosed, delaying appropriate treatment. We developed and validated the Anxiety, Abuse, and Somatization Questionnaire (AASQ), a quick and clinically practical tool to differentiate PNES from epilepsy.

Method: We retrospectively identified psychological variables that differentiated epilepsy from PNES in a discovery cohort of patients admitted to a video-electroencephalography monitoring (VEM) unit from 2002 to 2017. From these findings, we developed the AASQ and prospectively validated it in an independent cohort of patients with gold-standard VEM diagnosis.

Results: One thousand two hundred ninety-one patients were included in the retrospective study; mean age was 39.5 years (range: 18-99), 58% were female, 67% had epilepsy, and 33% had PNES. Psychometric data for 192 instrument items were reviewed, receiver operating characteristic curves were computed, and a 20-item AASQ was created. Prospective validation in 74 patients showed that a one-point increase in the AASQ score was associated with 11 times increase in the odds of having PNES compared with epilepsy. Low scores on the AASQ were associated with a low probability of PNES with a negative predictive value of 95%.

Significance: The AASQ is quick, inexpensive, and clinically useful for workup of seizure disorders. The AASQ excludes PNES with a high degree of confidence and can predict PNES with significance when combined with basic clinicodemographic variables. Future research will investigate diagnostic performance of the AASQ in relevant clinical subgroups, such as patients with comorbid epilepsy and PNES.
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http://dx.doi.org/10.1016/j.yebeh.2020.107482DOI Listing
November 2020

A 10 year retrospective cohort study of inpatients with younger-onset dementia.

Int J Geriatr Psychiatry 2021 02 16;36(2):294-301. Epub 2020 Sep 16.

Neuropsychiatry, NorthWestern Mental Health, Melbourne Health, Royal Melbourne Hospital, Parkville, Australia.

Objectives: Younger-onset dementia (YOD) refers to a dementia where symptom onset occurs when the patient is less than 65 years of age. YOD is far less common than late-onset dementia (occurring when patients are over 65 years old) and more challenging to diagnose due to its heterogeneous presentation. There have been relatively few studies describing demographic and diagnostic characteristics of patients with YOD in the community, particularly with follow-up information.

Methods: A retrospective cohort study was performed of inpatients admitted to a tertiary neuropsychiatry service, located in metropolitan Victoria, Australia, from 2009 to 2019. Inpatients with a YOD diagnosis were identified and data regarding diagnosis, demographics and investigations were obtained.

Results: There were 849 individual inpatients who were admitted to the service in the 10-year period and received comprehensive assessment. There were 306 individuals who received a YOD diagnosis, using contemporaneous diagnostic criteria (frequency 36%). The most common diagnoses were Alzheimer's disease (24.2%), frontotemporal dementia (23.1%), Huntington's disease (16.7%) and vascular dementia (7.8%). More than half of these inpatients were followed up and 6.5% had a diagnostic change when reviewed.

Conclusions: This study reports on the largest cohort of YOD to date, with diagnostic breakdown similar to previous retrospective file reviews. The neuropsychiatry service is funded to follow-up its patients, thus allowing re-assessment and continuity of care. While there are limitations in this study such as the lack of neuropathological outcomes, the findings emphasise the strengths of follow-up and appropriate service provision for these patients.
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http://dx.doi.org/10.1002/gps.5424DOI Listing
February 2021

Time to diagnosis in younger-onset dementia and the impact of a specialist diagnostic service.

Int Psychogeriatr 2020 Aug 28:1-9. Epub 2020 Aug 28.

Neuropsychiatry, NorthWestern Mental Health, Royal Melbourne Hospital, Parkville, Victoria3050, Australia.

Objectives: While early diagnosis of younger-onset dementia (YOD) is crucial in terms of accessing appropriate services and future planning, diagnostic delays are common. This study aims to identify predictors of delay to diagnosis in a large sample of people with YOD and to investigate the impact of a specialist YOD service on this time to diagnosis.

Design: A retrospective cross-sectional study.

Setting: The inpatient unit of a tertiary neuropsychiatry service in metropolitan Victoria, Australia.

Participants: People diagnosed with a YOD.

Measurements And Methods: We investigated the following predictors using general linear modeling: demographics including sex and location, age at onset, dementia type, cognition, psychiatric diagnosis, and number of services consulted with prior to diagnosis.

Results: A total of 242 inpatients were included. The mean time to diagnosis was 3.4 years. Significant predictors of delay included younger age at onset, dementia type other than Alzheimer's disease (AD) and behavioral-variant frontotemporal dementia (bvFTD), and increased number of services consulted. These predictors individually led to an increased diagnostic delay of approximately 19 days, 5 months, and 6 months, respectively. A specialized YOD service reduced time to diagnosis by 12 months.

Conclusion: We found that younger age at onset, having a dementia which was not the most commonly occurring AD or bvFTD, and increasing number of services were significant predictors of diagnostic delay. A novel result was that a specialist YOD service may decrease diagnostic delay, highlighting the importance of such as service in reducing time to diagnosis as well as providing post-diagnostic support.
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http://dx.doi.org/10.1017/S1041610220001489DOI Listing
August 2020

Clinical Application of Findings From Longitudinal Studies of Younger-Onset Dementia: Rapid Review and Recommendations.

J Neuropsychiatry Clin Neurosci 2020 13;32(4):322-333. Epub 2020 May 13.

Neuropsychiatry, Royal Melbourne Hospital, Parkville, Victoria, Australia (Loi, Goh, Walterfang, Velakoulis); Melbourne Neuropsychiatry Centre, University of Melbourne and Melbourne Health, Victoria, Australia (Loi, Goh, Walterfang, Velakoulis); National Ageing Research Institute, Parkville, Australia (Goh); and Florey Institute of Neuroscience and Mental Health, Parkville, Australia (Walterfang).

Younger-onset dementia (YOD) presents with heterogeneous symptoms, has a variety of etiologies, and can be difficult to diagnose. The authors conducted a rapid review of longitudinal YOD cohorts and their related substudies to evaluate current literature that may inform the clinical information provided to patients about the progression and duration of illness and to highlight areas for future research. Searches were conducted using MEDLINE, CINAHL, PubMed, PsycINFO, and Web of Science for articles published between January 1966 and June 2018. Four longitudinal YOD cohort studies and their related substudies were identified. Alzheimer's disease (AD) was reported as the most frequently occurring YOD. The age at onset reported for two cohorts ranged from 53.8 to 60.2 years, depending on the dementia type. Three cohorts yielded substudies that focused on other aspects of YOD, including caregiver outcomes, neuropsychiatric symptoms, and psychotropic drug use. There were conflicting data regarding whether AD or frontotemporal dementia had the greatest rate of cognitive decline. The authors identified a restricted amount of clinical information that may be useful for patients and their families. Limitations included relatively short follow-up periods and types of dementia included. There was also a lack of information on longitudinal changes in neuropsychiatric symptoms and their relationship to biomarkers. These aspects are important considerations for future research, because they may yield information relevant to early diagnosis and disease progression, with improved clinical care for patients with YOD and their families. Streamlining data collection may also improve the ability to generalize results.
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http://dx.doi.org/10.1176/appi.neuropsych.19110238DOI Listing
May 2020

Alcohol Use, Mental Health, and Functional Capacity as Predictors of Workplace Disability in a Cohort With Manifest Huntington's Disease.

J Neuropsychiatry Clin Neurosci 2020 27;32(3):235-243. Epub 2020 Feb 27.

Department of Psychiatry, Academic Unit for Psychiatry of Old Age, University of Melbourne, Melbourne (Goh, You, Perin, Lautenschlager, Chong, Ames, Chiu, Ellis); Neuropsychiatry Unit, Melbourne Neuropsychiatry Centre, Royal Melbourne Hospital, Melbourne (Goh, Loi); Department of Psychiatry, University of Melbourne, Melbourne (Goh, Lautenschlager, Clay, Ellis); NorthWestern Mental Health, Melbourne Health, Melbourne (Goh, Lautenschlager, Ellis); National Ageing Research Institute, Parkville, Australia (Goh); Department of Psychiatry, St. Vincent's Hospital, University of Melbourne, Melbourne (Chong); School of Psychological Sciences, University of Melbourne, Melbourne (Ellis); Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne (Ellis).

Objective: Huntington's disease (HD) is an inherited neurodegenerative disease involving motor, cognitive, psychiatric, and behavioral impairments that eventually affect work-role functioning. There is limited research regarding predictors of workplace disability in HD. The authors examined predictors of work impairment and disability in a cross-sectional cohort of employed persons with symptomatic HD participating in the worldwide Enroll-HD study.

Methods: The study sample (N=316) comprised individuals with manifest HD and a CAG repeat length range between 39 and 60 and were currently engaged in paid full- or part-time employment. Univariate and multivariate logistic regression analyses identified predictors and the effect of all predictors in a fully adjusted model.

Results: Of the sample, 20.3% reported missing work due to HD, 60.1% reported experiencing impairment while working due to HD, 79.1% reported having work-related activity impairment due to HD, and 60.8% reported impairment in overall work productivity due to HD. Individuals had 25% higher odds of missing work time if they had a higher level of functional impairment (odds ratio=0.76, 95% CI=0.64, 0.91) and had three times greater odds of missing work if they were current alcohol drinkers, compared with nondrinkers (odds ratio=2.86, 95% CI=1.62, 5.03). Individuals with lower self-perceived mental health were also 5% more likely to experience impairment at work due to HD. Motor impairment was not a strong predictor of workplace disability.

Conclusions: These findings provide important new knowledge that can inform the development of strategies or targeted intervention trials to support persons with symptomatic HD to maintain their work roles.
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http://dx.doi.org/10.1176/appi.neuropsych.19090199DOI Listing
May 2021

The dawn of robust individualised risk models for dementia.

Lancet Neurol 2019 11 13;18(11):985-987. Epub 2019 Sep 13.

Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC, Australia.

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http://dx.doi.org/10.1016/S1474-4422(19)30353-9DOI Listing
November 2019

A pilot study of the utility of cerebrospinal fluid neurofilament light chain in differentiating neurodegenerative from psychiatric disorders: A 'C-reactive protein' for psychiatrists and neurologists?

Aust N Z J Psychiatry 2020 01 21;54(1):57-67. Epub 2019 Jun 21.

Neuropsychiatry Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia.

Objective: Neurofilament light has shown promise as a biomarker for diagnosis, staging and prognosis in a wide range of neurological and neurodegenerative disorders. This study explored the utility of cerebrospinal fluid neurofilament light in distinguishing primary psychiatric disorders from neurodegenerative and neurological disorders, a common diagnostic dilemma for psychiatrists and neurologists.

Methods: This cross-sectional retrospective pilot study assessed cerebrospinal fluid neurofilament light on patients referred to a tertiary neuropsychiatry service from 2009 to 2017 for diagnostic assessment of neuropsychiatric and neurocognitive symptoms, where a neurodegenerative disorder was a differential diagnosis, who received lumbar punctures as part of a comprehensive workup. The most recent gold-standard clinical consensus diagnosis was categorised into psychiatric disorder or neurodegenerative or neurological disorder. Data from healthy controls were available for comparison. Data extraction and diagnostic categorisation was blinded to neurofilament light results.

Results: A total of 129 participants were included: 77 neurodegenerative or neurological disorder (mean age 57 years, including Alzheimer's dementia, frontotemporal dementia), 31 psychiatric disorder (mean age 51 years, including schizophrenia, major depressive disorder) and 21 healthy controls (mean age 66 years). Neurofilament light was significantly higher in neurodegenerative or neurological disorder (M = 3560 pg/mL, 95% confidence intervals = [2918, 4601]) compared to psychiatric disorder (M = 949 pg/mL, 95% confidence intervals = [830, 1108]) and controls (M = 1036 pg/mL, 95% confidence intervals = [908, 1165]). Neurofilament light distinguished neurodegenerative or neurological disorder from psychiatric disorder with an area under the curve of 0.94 (95% confidence intervals = [0.89, 0.98]); a cut-off of 1332 pg/mL was associated with 87% sensitivity and 90% specificity.

Conclusion: Cerebrospinal fluid neurofilament light shows promise as a diagnostic test to assist with the often challenging diagnostic dilemma of distinguishing psychiatric disorders from neurodegenerative and neurological disorders. Further studies are warranted to replicate and expand on these findings, including on plasma neurofilament light.
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http://dx.doi.org/10.1177/0004867419857811DOI Listing
January 2020

Huntington's disease: Neuropsychiatric manifestations of Huntington's disease.

Australas Psychiatry 2018 Aug 16;26(4):366-375. Epub 2018 Jul 16.

Clinical Associate Professor, Neuropsychiatry Unit, Royal Melbourne Hospital, Parkville, VIC, and; Melbourne Neuropsychiatry Centre, University of Melbourne, Melbourne, VIC, and; Associate Professor and Acting Head, Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra Hospital, Canberra, ACT, Australia.

Objectives: Huntington's disease (HD) is a profoundly incapacitating, and ultimately fatal, neurodegenerative disease. HD is presently incurable, so the current goal is to allow affected individuals to live as well as possible with the illness, to maximise functional independence and quality of life for the person with HD, their carers and family members. This clinical update review focuses on the common neuropsychiatric manifestations in HD, and outlines and evaluates the various neuropsychiatric facets of HD, including the aetiology, symptoms and diagnosis.

Conclusions: Neuropsychiatric symptoms can precede the classic motor clinical symptoms of HD (prodromal HD) by decades, and cause significant functional impairment. HD provides key insights and understanding into the organic psychiatric disorders, including contemporary clinical insights into the process of neurodegeneration and manifestation of neuropsychiatric symptoms.
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http://dx.doi.org/10.1177/1039856218791036DOI Listing
August 2018

Huntington's disease: Managing neuropsychiatric symptoms in Huntington's disease.

Australas Psychiatry 2018 Aug 24;26(4):376-380. Epub 2018 Apr 24.

Neuropsychiatrist, Neuropsychiatry Unit, Royal Melbourne Hospital, Parkville, VIC, and; Melbourne Neuropsychiatry Centre, University of Melbourne, Parkville, VIC, and; Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra Hospital, Canberra, ACT, Australia.

Objectives: This clinical update review focuses on the management of the neuropsychiatric manifestations of Huntington's disease (HD). The review highlights current issues regarding pharmacological and non-pharmacological treatment, putative therapeutics and recent relevant research findings in this area.

Conclusions: Neuropsychiatric symptoms may precede the classic motor clinical symptoms of HD (prodromal HD) by decades and cause significant functional impairment. Early recognition and comprehensive non-pharmacological, usually in combination with pharmacological, treatment is essential.
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http://dx.doi.org/10.1177/1039856218766120DOI Listing
August 2018

Alzheimer disease: Non-pharmacological and pharmacological management of cognition and neuropsychiatric symptoms.

Australas Psychiatry 2018 Aug 19;26(4):358-365. Epub 2018 Apr 19.

Neuropsychiatrist, Melbourne Neuropsychiatry Centre, University of Melbourne, Parkville, VIC, and; Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra, ACT, Australia.

Objectives: This clinical update review focuses on the management of cognition and the neuropsychiatric features of Alzheimer's disease (AD) and highlights current issues regarding pharmacological and non-pharmacological treatment, putative therapeutics and recent relevant research findings in this area.

Conclusions: AD is a neurodegenerative progressive condition characterised by cognitive impairment and functional decline. Most people with AD will demonstrate neuropsychiatric features, better known as behavioural and psychological symptoms of dementia (BPSD). Early recognition and treatment of BPSD are essential, as these cause considerable distress and carer burden. While there are many disease-modifying therapies for the cognitive symptoms still in the research stage, only symptomatic treatments are currently available for these and the BPSD.
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http://dx.doi.org/10.1177/1039856218766123DOI Listing
August 2018

Alzheimer's disease: clinical update on epidemiology, pathophysiology and diagnosis.

Australas Psychiatry 2018 Aug 3;26(4):347-357. Epub 2018 Apr 3.

Clinical Associate Professor, Neuropsychiatry Unit, Royal Melbourne Hospital, Parkville, VIC, and; Melbourne Neuropsychiatry Centre, University of Melbourne, Melbourne, VIC, and; Associate Professor and Acting Head, Academic Unit of Psychiatry and Addiction Medicine, Australian National University Medical School, Canberra Hospital, Garran, ACT, Australia.

Objectives: To provide a clinical update for general psychiatrists on the assessment and diagnosis of Alzheimer's disease (AD), highlighting current issues regarding epidemiology, risk factors and pathophysiology from recent relevant research findings.

Conclusions: Psychiatrists can apply their skills and training in the diagnosis of AD, which is based upon a comprehensive assessment comprising history, investigations, and cognitive and functional assessment, guided by accepted diagnostic criteria.
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http://dx.doi.org/10.1177/1039856218762308DOI Listing
August 2018

A pilot study exploring staff acceptability of a socially assistive robot in a residential care facility that accommodates people under 65 years old.

Int Psychogeriatr 2018 07 4;30(7):1075-1080. Epub 2017 Dec 4.

NorthWestern Mental Health,Melbourne Health,Parkville,Victoria,Australia.

ABSTRACTSocially assistive robots have successfully been trialed in residential care facilities (RCFs) for older adults. These robots may have potential for younger adults (i.e. under 65 years old) who also live in RCFs. However, it is important to investigate staff acceptability and ease-of-use of these robots. This pilot study used the Technology Acceptance Model to investigate how staff working in a specialized RCF for younger adults accept Betty, a socially assistive robot who was introduced in the facility for 12 weeks. Twenty-four staff completed pre-questionnaires, reporting that they thought Betty would have the ability to engage and entertain the residents they cared for. While there were only eight staff who completed the post-questionnaires, there were significant improvements compared to the pre-questionnaire results in areas such as residents enjoying the contact and activities. Impacting on ease-of use were technical difficulties. Although this study had limitations and could be improved by a better response rate and investigating the residents' acceptability of Betty, this study is one of the first to report that this novel technology may have much potential for engaging adults in RCFs.
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http://dx.doi.org/10.1017/S1041610217002617DOI Listing
July 2018

Modern technology to support carers of care recipients with dementia or functional mental illness: promising progress, but a long road ahead.

Int Psychogeriatr 2017 12;29(12):1933-1935

Department of Psychiatry,Technische Universität München,Munich,Germany.

There is no doubt that family carers who look after a family member with dementia or with a functional mental illness fulfill an important role, not only for their loved one, but also for the health and aged care systems of the countries they live in. Due to increasing life expectancy, but also improved healthcare the number of family carers supporting older care recipients with functional mental illness or dementia is on the rise. While the carer role often can offer rewarding experiences caregivers are at increased risk of stress, depression, sleep problems, and often experience poor health outcomes with increased morbidity and mortality (Oyebode, 2003). Next to the stressors directly associated with the carer role, they often do not have the time to engage in healthy behavior to protect their physical, mental, and cognitive health (Loi et al., 2014). There is a wealth of literature providing evidence about effective strategies to support carers and the recent Lancet Commission on Dementia prevention, intervention, and care highlighted the importance of exploring how the use of technological innovations could support carers better (Livingston et al., 2017). The use of modern technology in this context can mean a variety of approaches, such as internet-based programs to provide education and skill-building, virtual support to assist with monitoring and managing challenging behavior, online support groups, and the use of assistive or therapeutic technology to improve safety, enable positive activities, and support communication between carer and care recipient, to name just a few (D'Onofrio et al., 2017; Ienca et al., 2017; Livingston et al., 2017). More specifically, telehealth approaches via videoconferences have the potential to better support carers who live in rural or remote regions (O'Connell et al., 2014) or who cannot attend face-to-face support programs for other reasons such as inability to leave the care recipient alone at home, being a multiple carer or having a disability themselves to give just some examples.
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http://dx.doi.org/10.1017/S1041610217002150DOI Listing
December 2017

A pilot study investigating the feasibility of symptom assessment manager (SAM), a Web-based real-time tool for monitoring challenging behaviors.

Int J Geriatr Psychiatry 2018 04 3;33(4):576-582. Epub 2017 Nov 3.

Neuropsychiatry Unit, Melbourne Neuropsychiatry Centre, The University of Melbourne, NorthWestern Mental Health, Melbourne Health, Parkville, Victoria, Australia.

Objective: Improving and minimizing challenging behaviors seen in psychiatric conditions, including behavioral and psychological symptoms of dementia are important in the care of people with these conditions. Yet there is a lack of systematic evaluation of these as a part of routine clinical care. The Neuropsychiatric Inventory is a validated and reliable tool for rating the severity and disruptiveness of challenging behaviors. We report on the evaluation of a Web-based symptom assessment manager (SAM), designed to address the limitation of previous tools using some of the Neuropsychiatric Inventory functions, to monitor behaviors by staff caring for people with dementia and other psychiatric conditions in inpatient and residential care settings.

Methods: The SAM was piloted in an 8-bed inpatient neuropsychiatry unit over 5 months. Eleven nurses and 4 clinicians were trained in usage of SAM. Primary outcomes were usage of SAM and perceived usability, utility, and acceptance of SAM. Secondary outcomes were the frequencies of documented behavior. Usage data were analyzed using chi-square and logistic regression analyses.

Results: The SAM was used for all admitted patients regardless of diagnosis, with a usage rate of 64% for nurses regularly employed in the unit. Staff provided positive feedback regarding the utility of SAM.

Conclusions: The SAM appeared to offer individualized behavior assessment by providing a quick, structured, and standardized platform for assessing behavior in a real-world setting. Further research would involve trialing SAM with more staff in alternative settings such as in home or residential care settings.
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http://dx.doi.org/10.1002/gps.4820DOI Listing
April 2018

Deep brain stimulation for severe treatment-resistant obsessive-compulsive disorder: An open-label case series.

Aust N Z J Psychiatry 2018 07 30;52(7):699-708. Epub 2017 Sep 30.

1 Neuropsychiatry Unit, The Royal Melbourne Hospital, Parkville, VIC, Australia.

Objective: Deep brain stimulation can be of benefit in carefully selected patients with severe intractable obsessive-compulsive disorder. The aim of this paper is to describe the outcomes of the first seven deep brain stimulation procedures for obsessive-compulsive disorder undertaken at the Neuropsychiatry Unit, Royal Melbourne Hospital. The primary objective was to assess the response to deep brain stimulation treatment utilising the Yale-Brown Obsessive Compulsive Scale as a measure of symptom severity. Secondary objectives include assessment of depression and anxiety, as well as socio-occupational functioning.

Methods: Patients with severe obsessive-compulsive disorder were referred by their treating psychiatrist for assessment of their suitability for deep brain stimulation. Following successful application to the Psychosurgery Review Board, patients proceeded to have deep brain stimulation electrodes implanted in either bilateral nucleus accumbens or bed nucleus of stria terminalis. Clinical assessment and symptom rating scales were undertaken pre- and post-operatively at 6- to 8-week intervals. Rating scales used included the Yale-Brown Obsessive Compulsive Scale, Obsessive Compulsive Inventory, Depression Anxiety Stress Scale and Social and Occupational Functioning Assessment Scale.

Results: Seven patients referred from four states across Australia underwent deep brain stimulation surgery and were followed for a mean of 31 months (range, 8-54 months). The sample included four females and three males, with a mean age of 46 years (range, 37-59 years) and mean duration of obsessive-compulsive disorder of 25 years (range, 15-38 years) at the time of surgery. The time from first assessment to surgery was on average 18 months. All patients showed improvement on symptom severity rating scales. Three patients showed a full response, defined as greater than 35% improvement in Yale-Brown Obsessive Compulsive Scale score, with the remaining showing responses between 7% and 20%.

Conclusion: Deep brain stimulation was an effective treatment for obsessive-compulsive disorder in these highly selected patients. The extent of the response to deep brain stimulation varied between patients, as well as during the course of treatment for each patient. The results of this series are comparable with the literature, as well as having similar efficacy to ablative psychosurgery techniques such as capsulotomy and cingulotomy. Deep brain stimulation provides advantages over lesional psychosurgery but is more expensive and requires significant multidisciplinary input at all stages, pre- and post-operatively, ideally within a specialised tertiary clinical and/or academic centre. Ongoing research is required to better understand the neurobiological basis for obsessive-compulsive disorder and how this can be manipulated with deep brain stimulation to further improve the efficacy of this emerging treatment.
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http://dx.doi.org/10.1177/0004867417731819DOI Listing
July 2018

Person-centered care and engagement via technology of residents with dementia in aged care facilities.

Int Psychogeriatr 2017 12 8;29(12):2099-2103. Epub 2017 Aug 8.

Academic Unit for Psychiatry of Old Age,Department of Psychiatry,The University of Melbourne,Parkville,Victoria,Australia.

Touchscreen technology (TT) is a resource that can improve the quality of life of residents with dementia, and care staff, in residential aged care facilities (RACF) through a person-centered care approach. To enable the use of TTs to engage and benefit people with dementia in RACFs, education is needed to explore how these devices may be used, what facilitates use, and how to address barriers. We sought to provide education and explore RACF staff views and barriers on using TT to engage their residents with dementia. An educational session on using TT with residents with dementia was given to staff from three long-term RACFs in Melbourne, Australia. A cross-sectional convenience sample of 17 staff members (personal care attendants, registered nurses, enrolled nurses, allied health clinicians, and domestic staff) who attended were administered questionnaires pre- and post-sessions. As a result of the education seminar, they were significantly more confident in their ability to use TT devices with residents. TT, and education to staff about its use with residents with dementia, is a useful strategy to enhance RACF staff knowledge and confidence, thereby enhancing the use of technology in RACFs in order to improve care standards in people with dementia.
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http://dx.doi.org/10.1017/S1041610217001375DOI Listing
December 2017

Dementia Literacy among Community-Dwelling Older Adults in Urban China: A Cross-sectional Study.

Front Public Health 2017 7;5:124. Epub 2017 Jun 7.

Dementia Care and Research Center, Peking University Institute of Mental Health (Sixth Hospital), Beijing, China.

Objective: Delay in seeking diagnosis of dementia is common in China. Misinformation and poor knowledge about dementia may contribute to it. The study was designed to explore the nationwide dementia literacy among older adults in urban China and to investigate the factors associated with overall dementia literacy.

Methods: In a cross-sectional study, a convenience sample of 3,439 community-dwelling old adults aged 60 and over was recruited from 34 cities in 20 provinces between June 20 and August 20, 2014. All participants were administered the face-to-face mental health literacy questionnaire, which included the prevalence, symptoms, intention, and options for treatment of dementia. Stepwise multivariate regression analysis was used to explore factors associated with overall dementia literacy.

Results: The response rate was 87.4%. The overall dementia literacy was 55.5% (SD = 20.9%) among all respondents. The correct response rate was higher for questions on symptoms (58.7-89.6%), but lower for questions on the prevalence (22.2%) and choosing appropriate professional care personnel (22.2%). Being male [ = 1.256, 95% CI (1.022-1.543)], having lower per capita annual income [OR = 1.314, 95% CI (1.064-1.623)], lower education [OR = 1.462, 95% CI (1.162-1.839)], and suspected depression [OR = 1.248, 95% CI (1.009-1.543)] were negatively associated with overall dementia literacy.

Conclusion: Dementia literacy among community-dwelling older adults in urban China remains very low, in particular about the impact of dementia and appropriate treatment personnel. Community educational programs aiming to close this knowledge gap are encouraged to focus on those in the population at highest risk of low dementia literacy.
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http://dx.doi.org/10.3389/fpubh.2017.00124DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5461251PMC
June 2017

An investigation of residential facility staff usage of touchscreen technology.

Int Psychogeriatr 2017 12 24;29(12):2095-2098. Epub 2017 Apr 24.

Academic Unit for Psychiatry of Old Age,Department of Psychiatry,University of Melbourne,Melbourne,Victoria 3052,Australia.

Older adults may become more familiar and interested in using touchscreen technology (TT). TT can be used to engage older adults living in residential aged care facilities (RACFs) and staff there can play an important role in supporting residents to use TT. However, before these are introduced, it is crucial to investigate their opinions in using TT with residents. A questionnaire based on the Technology Acceptance Model was administered to assess staff usage and confidence in using TT, their perceptions in TT ease-of-use and usefulness in helping them care for their residents. Perhaps unsurprisingly, results found that respondents were familiar using TT. More importantly, staff reported that they were interested in engaging residents with TT and nominated different training methods to support them such as group in-services. This project provides information about staff experience and acceptance of the use of TT for residents in RACFs.
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http://dx.doi.org/10.1017/S1041610217000515DOI Listing
December 2017

Investigating the current methods of assessing behavioral and psychological symptoms in residential aged care facilities in a metropolitan city.

Int Psychogeriatr 2017 05 21;29(5):855-858. Epub 2016 Dec 21.

Academic Unit for Psychiatry of Old Age,Department of Psychiatry,The University of Melbourne,Australia.

Up to 90% of people with dementia living in residential aged care facilities (RACFs) display behavioral and psychological symptoms of dementia (BPSD), and these are associated with poorer quality of life and increased morbidity and mortality. In order to implement appropriate interventions, it is important to understand the symptoms in more detail. Despite the availability of BPSD assessment tools, it is unknown what the current practice of monitoring of BPSD in RACFs. We sought to investigate the current BPSD assessment tools being used in RACFs and explore different stakeholders' views on current practices. A cross-sectional convenience sample of 21 clinicians were identified and administered a questionnaire. Old age psychiatrists, aged psychiatry clinicians, behavior management teams and RACF staff completed the questionnaires. Clinicians reported that objective consistent information about BPSD were important for recommending and implementing pharmacological and non-pharmacological strategies for BPSD; however, the use of validated BPSD assessments in RACFs was not a usual part of clinical practice. RACF staff stated the major barrier to assessment of BPSD was lack of time. Alternate methods of assessing BPSD which consider preferences from clinicians and RACF staff should be further investigated. Modern technology which can allow "real time" assessment may be a solution.
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http://dx.doi.org/10.1017/S104161021600226XDOI Listing
May 2017

A pilot study using "apps" as a novel strategy for the management of challenging behaviors seen in people living in residential care.

Int Psychogeriatr 2017 04 15;29(4):637-643. Epub 2016 Dec 15.

Academic Unit for Psychiatry of Old Age,Department of Psychiatry,The University of Melbourne,Melbourne,Australia.

Background: Many adults living in residential care will demonstrate challenging behaviors. Non-pharmacological strategies are recommended as first-line treatment. Using applications (apps) is a novel approach to managing these behaviors, and has yet to be assessed in this group. This paper describes a pilot study to test apps as a novel non-pharmacological strategy to manage challenging behaviors in adults living in residential care.

Methods: A non-blinded, non-randomized crossover trial design was implemented which compared apps to a control situation and usual care to determine whether apps were able to decrease challenging behaviors. The primary outcome measure was the Neuropsychiatric Inventory (NPI) that measures the frequency and severity of these behaviors.

Results: Fifteen residents participated whose mean age was 78.5 years. There were a range of diagnoses and comorbidities, including dementia and schizophrenia. IPads were used as the medium for delivering the apps and residential care staff implemented the interventions. There was a significant decrease in the total NPI score using the apps intervention (10.6 points) compared to the control (17.7 points) and to usual care (21.1 points). There was positive qualitative feedback from the staff who were involved in the study, but they also cited barriers such as lack of confidence using the apps and lack of time.

Conclusions: Although this was a small and limited study, results suggest that using apps may be a feasible and personalized approach to managing challenging behaviors. A more rigorous study design that includes larger sample sizes and staff training may enable further research and benefits in this area.
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http://dx.doi.org/10.1017/S1041610216002039DOI Listing
April 2017

Can a short internet training program improve social isolation and self-esteem in older adults with psychiatric conditions?

Int Psychogeriatr 2016 10 4;28(10):1737-40. Epub 2016 Jul 4.

Academic Unit for Psychiatry of Old Age,Department of Psychiatry,University of Melbourne,34-54 Poplar Road,Parkville,Victoria,3052,Australia.

The purpose of this study was to investigate whether an educational training course on using the internet and touchscreen technology (TT) would decrease social isolation and improve self-esteem in residents living in a low-level residential facility. Twelve sessions over six weeks with two facilitators were provided to five participants with a variety of psychiatric disorders. Measures were completed before and after the 12 sessions. There were no statistically significant improvements or worsening in social isolation (mean score 6.2, SD 3.35) or self-esteem (mean score 18.2, SD 3.56) post the training sessions for the residents. Qualitative feedback suggested that the residents enjoyed this experience and learnt new skills. Further study is recommended using larger samples and alternative outcomes measures.
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http://dx.doi.org/10.1017/S1041610216001022DOI Listing
October 2016

Therapeutic advances and risk factor management: our best chance to tackle dementia?

Med J Aust 2016 Feb;204(3):91-2, 91.e1

University of Melbourne, Melbourne, VIC.

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http://dx.doi.org/10.5694/mja15.01122DOI Listing
February 2016

The adverse mental health of carers: Does the patient diagnosis play a role?

Maturitas 2015 Sep 23;82(1):134-8. Epub 2015 Jun 23.

Academic Unit for Psychiatry of Old Age, Department of Psychiatry, University of Melbourne, Normanby House, St George's Hospital, 283 Cotham Road, Kew, Victoria 3101, Australia; School of Psychiatry and Clinical Neurosciences and the Western Australia Centre for Health and Ageing, University of Western Australia, Australia. Electronic address:

Objectives: The adverse mental health effects of caring have been studied, frequently in carers of people with dementia. Less is known about the mental health of carers of people with other conditions. This study compared depression and burden in older carers looking after people with a variety of conditions.

Design, Methods And Measures: Over 200 older carers interested in participating in the Improving Mood through Physical Activity in Carers and Care-recipient Trial were included in this cross-sectional study, using the Geriatric Depression Scale (GDS) and Zarit Burden Inventory (ZBI).

Results: Overall there were 43% of carers who were depressed and a quarter of them reported moderate-to-severe burden. Carers of people with physical conditions had the highest levels of depression and burden. Patient diagnosis, hours spent caring, and burden were associated with depression, while hours spent caring and carer depression were associated with burden. These factors contributed approximately 25-30% of the variance of depression and burden, respectively.

Conclusions: The diagnosis of the patient was a factor associated with depression, and older carers of people with physical conditions were at the highest risk. It is important for clinicians to assess the mental health of all carers, regardless of the patient diagnosis.
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http://dx.doi.org/10.1016/j.maturitas.2015.06.034DOI Listing
September 2015