Performance of the Rowland Universal Dementia Assessment Scale in Screening Mild Cognitive Impairment at an Outpatient Setting.

INTRODUCTION: Mild cognitive impairment (MCI) is defined as the symptomatic pre-dementia phase on the continuum of cognitive decline. Early recognition and application of potential interventions could prevent or delay the progression to dementia. The Rowland Universal Dementia Assessment Scale (RUDAS) shows good performance in the screening of dementia but has limited data regarding its diagnostic properties in the screening of MCI. The objectives of this study were to assess the psychometric properties of the Thai version of the RUDAS (RUDAS-Thai) in the screening of MCI, identify associated factors for the RUDAS performance, and determine the optimal cutoff point in detecting MCI. METHODS: This was a cross-sectional study conducted from January 2020 to March 2021. Older patients at the outpatient clinic of an internal medicine department at a tertiary care hospital in Thailand were examined. Baseline data were collected, and the RUDAS-Thai was administered to each patient. Afterward, a geriatrician assessed each patient for MCI. RESULTS: A total of 150 patients were included, of whom 42 cases (28%) had MCI. The overall performance of the test using an area under the receiver operating characteristic curve (AUC) was 0.82 (95% confidence interval 0.75-0.89). At the optimal cutoff point of 25/30, the AUC was 0.76 with sensitivity and specificity of 76.2 and 75%, respectively. The educational level affected the test performance according to regression analysis. For patients with years of education ≤6 and >6, the optimal cutoff points were 25/30 and 26/30, respectively. CONCLUSION: The RUDAS-Thai performed well in differentiating patients with MCI from normal cognition; however, it was affected by educational level. A score of 25/30 or lower for persons with ≤6 years of education or 26/30 or lower for persons with higher than 6 years of education is the optimal cutoff point for indication of developing MCI.

Cost-Effectiveness Analysis of Direct-Acting Oral Anticoagulants for Stroke Prevention in Thai Patients with Non-Valvular Atrial Fibrillation and a High Risk of Bleeding.

OBJECTIVE: The objective of this study was to assess the cost effectiveness of direct-acting oral anticoagulants for stroke prevention in Thai patients with non-valvular atrial fibrillation and a HAS-BLED score of 3. METHODS: Total costs (US$) in 2017 and quality-adjusted life-years were estimated over 20 years using a Markov model. A base-case analysis was conducted under a societal perspective, which included direct healthcare, non-healthcare and indirect costs in Thailand. Clinical events for warfarin and utilities were obtained from Thai patients whenever possible. The efficacy of direct-acting oral anticoagulants was derived from trial-based East Asian subgroups and adjusted for time in the target international normalized ratio range of warfarin. RESULTS: In the base case, use of apixaban instead of warfarin incurred an additional cost of US$20,763 per quality-adjusted life-year gained. Substituting apixaban with rivaroxaban and rivaroxaban with high-dose edoxaban would incur an additional cost per quality-adjusted life-year by US$507 and US$434, respectively. Compared with warfarin, high-dose edoxaban had the lowest incremental cost-effectiveness ratio of US$9704/quality-adjusted life-year, followed by high-dose dabigatran (incremental cost-effectiveness ratio US$11,155/quality-adjusted life-year). The incremental cost-effectiveness ratios based on a payer perspective were similar. The incremental cost-effectiveness ratio was below Thailand's cost-effectiveness threshold when high-dose dabigatran and edoxaban prices were reduced by 50%. Changes in key parameters had a minimal impact on incremental cost-effectiveness ratios. CONCLUSIONS: For both societal and payer perspectives, high-dose edoxaban with a price below the country cost-effectiveness threshold should be the first anticoagulant option for Thai patients with non-valvular atrial fibrillation and a high risk of bleeding.

National data on stroke outcomes in Thailand.

Stroke is a major public health problem worldwide. There are limited data on national stroke prevalence and outcomes after the beginning of the thrombolytic therapy era in Thailand. This study aimed to investigate the prevalence and factors associated with mortality in stroke patients in Thailand using the national reimbursement databases. Clinical data retrieved included individuals under the universal coverage, social security, and civil servant benefit systems between 1 October 2009 and 30 September 2010. The stroke diagnosis code was based on the International Classification of Diseases 10th revision system including G45 (transient cerebral ischemic attacks and related syndromes), I61 (intracerebral hemorrhage), and I63 (cerebral infarction). The prevalence and stroke outcomes were calculated from these coded data. Factors associated with death were evaluated by multivariable logistic regression analysis. We found that the most frequent stroke subtype was cerebral infarction with a prevalence of 122 patients per 100,000 of population, an average length of hospital stay of 6.8 days, an average hospital charge of 20,740 baht (∼$USD 691), a mortality rate of 7%, and thrombolytic prescriptions of 1%. The significant factors associated with stroke mortality were septicemia, pulmonary embolism, pneumonia, myocardial infarction, status epilepticus, and heart failure. In conclusion, the prevalence and outcomes of stroke in Thailand were comparable with other countries. The era of thrombolytic therapy has just begun in Thailand.

Cost differences between complete and incomplete post-exposure courses of rabies vaccination.

Courses of post-exposure rabies vaccination in clinical practice are often not administered completely. If suspected animals are still alive after 10 days of observation, full post-exposure vaccination will usually be withheld from bite victims. In this study, we compared the cost differences between complete and incomplete courses of post-exposure rabies vaccination. The cost calculations were based on the principle that all patients will have at least one more animal bite in the future. Costs were compared between patients who received post-exposure rabies vaccination and if they completed or did not complete the vaccine regimen. In this study, 46.7% of 372 patients completed the full course of five doses of the rabies vaccine. Based on the study rationale, complete vaccination would save nation budget 224,700 Baht for WHO wound category 2, 801,474 Baht for WHO wound category 3 with equine rabies immunoglobulin treatment, and 2,618,916 Baht for WHO wound category 3 with human rabies immunoglobulin treatment. Physicians should encourage complete courses of post-exposure rabies vaccination to save further costs from animal bites in the future.

Prevalence of factors associated with poor outcomes of hospitalized myasthenia gravis patients in Thailand.

OBJECTIVE: To examine the prevalence of hospitalized myasthenia gravis (MG), and to determine the factors associated with poor outcomes of hospitalized MG patients at a national level. METHODS: This study was based on a retrospective design. We collected data of hospitalized MG adults recorded by the National Health Security Office, Bangkok, Thailand between October 2009 and September 2010. Clinical data and treatment outcomes were examined. RESULTS: The total number of hospitalized MG patients was 936 cases. The prevalence rate of hospitalized MG patients was 2.17/100,000 population. The average age (SD) was 44.93 (14.16) years. Regarding the discharge status of MG patients, 845 cases (90.3%) had improved. The total hospital charge of MG patients was 64,332,806 baht (USD 2,144,426.87) or an average of 68,731.63 baht/admission (USD 2,291.05), with an average length of stay of 10.45 days. There were 3 significant factors associated with poor outcomes in hospitalized MG patients; namely, hospital category, pneumonia, and respiratory failure. CONCLUSION: The prevalence of admission in MG patients was 2.17 persons/100,000 population. Hospital category, pneumonia, and respiratory failure were significant factors associated with poor outcomes.

Burdens among caregivers of older adults with advanced cancer and risk factors.

UNLABELLED: Family caregivers of older cancer patients face many challenges in managing illness. The burden impacts physical, emotional, spiritual, and social health. The objective of this study was to identify burden among caregivers of older patients with advanced cancer, and associated factors. MATERIALS AND METHODS: Caregivers of older cancer patients were randomly interviewed from March-September 2012. Information on baseline characteristics and caregiver burden using the Zarit Burden Inventory (ZBI) was collected. Descriptive statistics were used to analyze baseline data, with univariate and multiple linear regression to analyze factors associated with higher burden. RESULTS: One hundred and fifty participants were assessed. The mean ZBI was 19.2 ± 12.9 (95%CI, 17.1, 21.2). Two-thirds of caregivers reported no burden (63%) and the main impact variable on ZBI was guilt. High burdens were associated with single caregiver, relationship with the patient as siblings, presence of migraines, and cancer types of the patients. CONCLUSIONS: Caregiver burden of Thai cancer patients is low. This unexpected small number could be the result of the socio-cultural viewpoint. Assessment of caregivers and focusing on related factors should be incorporated into treatment plans.

A national database of incidence and treatment outcomes of status epilepticus in Thailand.

Status epilepticus (SE) is a serious neurological condition. The national database of SE in Thailand and other developing countries is limited in terms of incidence and treatment outcomes. This study was conducted on the prevalence of status epilepticus (SE). The study group comprised of adult inpatients (over 18 years old) with SE throughout Thailand. SE patients were diagnosed and searched based on ICD 10 (G41) from the national database. The database used was from reimbursement documents submitted by the hospitals under the three health insurance systems, namely, the universal health coverage insurance, social security, and government health welfare system during the fiscal year 2010. We found 2190 SE patients receiving treatment at hospitals (5.10/100 000 population). The average age was 50.5 years and 1413 patients were males (64.5%). Mortality rate was 0.6 death/100 000 population or 11.96% of total patients. Significant factors associated with death or a nonimproved status at discharge were type of insurance, hospital level, chronic kidney disease, having pneumonia, having shock, on mechanical ventilator, and having cardiopulmonary resuscitation. In conclusion, the incidence of SE in Thailand was 5.10/100 000 population with mortality rate of 0.6/100 000 population.

Cost minimization of HLA-B*1502 screening before prescribing carbamazepine in Thailand.

BACKGROUND: Carbamazepine (CBZ) is broadly used for the treatment of epilepsy, neuropathic pain and other neurological diseases, owing to its effectiveness and low price. CBZ can induce Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). There are several studies that found an association between HLA-B*1502 and CBZ-induced SJS/TEN, especially in people of Thai origin. In Thailand the prevalence of HLA-B*1502 was found to be in the range 8.1-14 %. OBJECTIVE: This study aimed to determine if screening for HLA-B*1502 in Thai patients who were to receive CBZ is cost effective. Setting Srinagarind Hospital, Khon Kaen University, Thailand. METHOD: A comparison between treatment cost of CBZ induced SJS/TEN and the HLAB*1502 screening costs in the Thai population. MAIN OUTCOME MEASURE: Comparison of the costs of treatment of CBZ induced SJS/TEN and costs of HLA-B*1502 screening test. Results When persons having the HLA-B*1502 allele receive CBZ, the chance of developing SJS/TEN is as high as 88.1 %, while persons without the HLA-B*1502 allele do not develop SJS/TEN. Therefore, a model was calculated to compare the cost of treatment between HLA-B*1502 testing before giving CBZ and if the patients were not tested for HLAB*1502. It was found that screening 100 patients before giving CBZ would save an amount of 98,549.94 baht per 100 cases of CBZ-prescribed patients. CONCLUSION: The screening for HLA-B*1502 allele before giving carbamazepine is cost effective. The results of the present study may also apply to other populations if the HLA-B*1502 frequency is high enough.

Caregivers burden of older adults with chronic illnesses in the community: a cross-sectional study.

A chronic physical/mental disease not only has direct consequences for the chronically-ill older adults but can also alter the caregiver's life. The objectives of this study were to identify burdens of community-dwelling older adults, characteristics of caregivers, severity of caregiver burden, and to develop supportive strategies. Caregivers of community-dwelling older adults were randomly interviewed between February and March 2012. Information on baseline characteristics and caregiver burden using Zarit Burden Inventory (ZBI) was collected. One hundred-fifty caregivers were interviewed. The mean ZBI was 20.8 + 11.3 [95% CI 19.0, 22.7]. The majority of caregiver burden was classified as no burden (52%). The age of caregivers, self-reported health status and duration of care had a positive relationship with ZBI scores while self-reported income had a negative one. Caregiver burden among Thai community-dwelling elder persons was small as most of those cared for had uncomplicated illness but this might be underestimated. Caregiver-dependent factors were more strongly associated with high burden than patient characteristics. Healthcare providers should consider these factors for interventions to alleviate burden.

Delirium in hospitalized elderly patients of Thailand; is the figure underrecognized?

BACKGROUND: Delirium is a frequent complication associated with hospitalization of older adults leading to serious complications but it is potentially preventable. The overall data regarding admission rates and its impact in Thai geriatrics are limited. OBJECTIVE: To identify admission, mortality rates of older persons with delirium and its consequences. MATERIAL AND METHOD: Information on illness of inpatients and casualties came from hospitals nationwide and from hospital withdrawals from the three health insurance schemes in fiscal 2010. The data included 96% of the population. The data were analyzed by age groups in delirious patients. RESULTS: Delirium occurred in 11,410 of all admissions; contributing admission and mortality rates of 155.4 and 6.4/100,000 older persons. These figures increased with age. The average length of stay in persons with and without delirium were 22.3 and 5.4 days and the average hospital charges were 53,174 and 18,230.8 Baht, respectively. CONCLUSION: The admission rate of patients with delirium was lower than prior reports; underdetection and underreport should be considered. Admission and mortality rates rose with age. There was an increase in length of stay and hospital charges.

Can Rowland Universal Dementia Assessment Scale (RUDAS) replace Mini-mental State Examination (MMSE) for dementia screening in a Thai geriatric outpatient setting?

Mini-mental-State Examination (MMSE) is a widely used tool for dementia screening. However, several limitations are found and the Rowland Universal Dementia Assessment Scale (RUDAS) appears to be an alternative test. The objective in this study was to compare the performance of MMSE-Thai 2002 and RUDAS-Thai for dementia screening, and to determine their performances and identify their optimal cut-off points. The participants were older patients from a Geriatric and Neurology Outpatient Clinic, Srinagarind Hospital, Khon Kaen University. The RUDAS-Thai and the MMSE-Thai 2002 were administered to each participant. Subsequently, a specialist physician assessed each participant for dementia. Results showed the area under receiver operating characteristic curve for both RUDAS-Thai (81.0%; 95%CI, 74.8-87.2) and MMSE-Thai 2002 (81.2%; 95%CI, 74.9-87.4) were equal. A score of 24 or lower provided an optimal cut-off point. Our finding supports that the RUDAS-Thai can be an effective alternative test for dementia screening. For both test scores, a score of 24 or lower is an optimal cut-off point to provide an indication of developing dementia.

The performance of the Rowland Universal Dementia Assessment Scale (RUDAS) for cognitive screening in a geriatric outpatient setting.

BACKGROUND AND AIMS: Dementia is prevalent in the elderly but it is usually unrecognized. The Rowland Universal Dementia Assessment Scale (RUDAS) appears to be a good screening tool for dementia detection. The objectives are to validate RUDAS-Thai for detecting dementia according to Diagnostic and Statistical Manual of Mental Disorders- IV-Text Revised (DSM-IV-TR) criteria in a geriatric outpatient setting and to determine its optimal cut point. METHODS: This is a cross-sectional study in which the target population is patients from a Geriatric and Neurology Outpatient Clinic, Srinagarind Hospital, Khon Kaen University who were aged 60 years or above. The content validity and test-retest reliability of the RUDAS-Thai were performed initially. It was administered to each participant. Then a specialist physician assessed each participant for dementia. RESULTS: Eighty-nine (44.5%) subjects had dementia, 89 (44.5%) had normal cognition and 22 (11%) had mild cognitive impairment. The area under the Receiver operating characteristic (ROC) curve was 0.82 (0.75-0.87). The optimal cut point was 24/30; it provided sensitivity and specificity of 78.7% and 61.8%, respectively. It was not influenced by age and gender but by educational level. CONCLUSIONS: The RUDAS-Thai is a good screening tool for dementia detection in a geriatric outpatient setting. It is portable, short-time consuming, and avoids some limitations of the Mini-Mental State Examination (MMSE). However, education does affect the scores. The scores of 24 or lower is an optimal cut point for an indication of developing dementia.