Hearing and vision health for people with dementia in residential long term care: Knowledge, attitudes and practice in England, South Korea, India, Greece, Indonesia and Australia.

OBJECTIVES: Up to 90% of people with dementia in long term care (LTC) have hearing and/or vision impairment. Hearing/vision difficulties are frequently under-recognised or incompletely managed. The impacts of hearing/vision impairment include more rapid cognitive decline, behavioural disturbances, reduced quality of life, and greater care burden. This research investigated LTC staff knowledge, attitudes and practice regarding hearing/vision care needs for residents with dementia. METHODS: A survey of staff in LTC facilities in England, South Korea, India, Greece, Indonesia and Australia. Respondents used a five-point scale to indicate agreement or YES/NO response to questions regarding sensory-cognitive care knowledge (what is known); attitudes (what is thought); practice (what is done). RESULTS: Respondents reported high awareness of hearing/vision care needs, although awareness of how to identify hearing/vison difficulties or refer for assessment was low. Most felt that residents were not able to use hearing/vision devices effectively due to poor fit, being poorly tolerated or lost or broken devices. A substantial minority of respondents reported low confidence in supporting use of assistive hearing/vision devices, with lack of training the main reason. Most staff did not undertake routine checking of hearing/vision devices, and it was rare for facilities to have designated staff responsible for sensory needs. Variation among countries was not significant after accounting for staff experience and having received dementia training. CONCLUSIONS: There is a need to improve sensory support for people with dementia in LTC facilities internationally. Practice guidelines and training to enhance sensory-cognitive knowledge, attitudes and practice in professional care teams is called for.

Regulation of Long-Term Care Homes for Older Adults in India.

The rising aging population in India has led to an increased caregiving burden, and accordingly, the number of residential care facilities is also burgeoning. There is no regulatory framework or registration authority specifically for residential care homes in India. The article's objective is to understand the need for a regulatory framework in India in the context of historic and global experiences in the UK, USA, and Europe. Although there is a lack of literature comparing the community home-based care and residential care, one study reported a preference for home-based care in the South Asian context. Elder abuse and deprivation of rights of seniors are common, and there is a need to bring in more safeguards to prevent these from the perspective of the older adults, their family members, the care providers, and the state. While the main priority of meeting care needs in long-term care is a challenge given the lack of trained care staff, the quality control mechanisms also need to evolve. A review of adverse incidents, complaints, and litigations also highlights the need for regulation to improve the standards and quality of care. The article explores lacunae of residential care facilities in the Indian context and provides recommendatory parameters for evaluating the quality of care provided. Relevant sections of the statutory new Mental Healthcare Act of 2017 in India could provide a regulatory framework ensuring rights and liberties of the residents are upheld. The authors propose a state-run model for elderly care homes and commencement of framing regulations appropriate to the Indian context.

Unexplored Needs of the Older Adults: Experiences From Elders Helpline in Bengaluru.

Elders Helpline has been operational in Bangalore by joint effort of the Nightingales Medical Trust (NMT) and the City Police since its inception in 2002. The Elders Helpline is unique as it is the first of its kind in India that offers services for the welfare of the older people in Bangalore city. The objectives of this article were to review the process of setting up of the helpline services, its evolution, range of services offered, to evaluate the services to ascertain the social difficulties with a focus on abuse experienced by the older people in Bangalore and find out the common themes. From the records, the Elders Helpline has responded to as many as 144058 calls between April 2009 and March 2020. This article reviewed functions of the Elders Helpline including supervision and training to its staff members, offering counselling to the Older adults by resolving family conflicts and other social issues by upholding and safeguarding their rights. The article highlights the need and impact of Elders Helpline suggesting the need to expand this type of Helpline to other Districts of the country. This study indicates that the Elders Helpline has become a platform for the elderly people to express their concerns and to make them feel secure. The Elders Helpline model is now launched nationally in October 2021 through the expansion of helpline services. There is a need to gather more comprehensive data and for ongoing research and training to reach out many needy older people.

Assessment of the Financial Capacity in Elderly: Approach and Challenges in Indian Scenario.

The elderly population, with those individuals above the age of 60 years, is increasing exponentially, attributable to higher life expectancy as a result of improved health care, socioeconomic level, and quality of life. As they grow older (>80 years), it becomes difficult to manage their basic needs and daily living. A report on Decade of Healthy Ageing estimates that 14% of people aged 60 years and above cannot meet their basic daily needs which include the ability to manage finances. Some elderly people depend on others to manage finances because of their inability to make decisions resulting in conflicts and communication problems between siblings and other members of the family and lodging of civil lawsuits in India's joint family unit. So, decision-making is an important area to assess in the elderly people, given its clinical, legal, and ethical aspects. Courts of law can refer to older persons for assessing their capacity to manage finances, though there are no structured clinical procedures to assess it in India. This article evaluates existing methods around the world, discusses the challenges associated with the assessment, and provides clinicians with guidance on assessing financial capacity from an Indian perspective.

Approach to Management of Wandering in Dementia: Ethical and Legal Issue.

Wandering behavior is one of the most important and challenging management aspects in persons with dementia. Wandering behavior in people with dementia (PwD) is associated with an increased risk of falls, injuries, and fractures, as well as going missing or being lost from a facility. This causes increased distress in caregivers at home and in healthcare facilities. The approach to the comprehensive evaluation of the risk assessment, prevention, and treatment needs more strengthening and effective measures as the prevalence of wandering remains high in the community. Both the caregiver and clinicians need a clear understanding and responsibility of ethical and legal issues while managing and restraining the PwD. Ethical and legal issues especially in the light of the new Indian Mental Healthcare Act of 2017, related to confinement by family members in their homes by family caregivers, seclusion, physical or chemical restraints, other pharmacological and behavioral treatment, highlighting their effectiveness as well as adverse consequences are discussed. This article attempts to address an approach in managing wandering behavior in PwD in light of MHCA, 2017.

Hybrid Telepsychiatry: A United States Perspective with Relevance to India.

Telepsychiatry provides a platform for mental health care delivery in rural and remote areas. Hybrid Telepsychiatry model combines home-based telepsychiatry with domiciliary visits by community mental health workers. This involves use of different modes of teledevices which ensures safe and secure clinical platform. Research evidence supports that incorporating this model seems to use the specialist time efficiently where the resources are limited and services need to be catered for larger geographical community. The current telepsychiatry practice in the United States, specifically the hybrid model, has indisputably shown significant benefits in caring for psychiatric patients. Such valuable clinical model and its relevance to current mental practice and also its application in the Indian scenario can be helpful in providing comprehensive multidisciplinary treatment. This review evaluates and highlights the potential risks and benefits of adopting the hybrid telepsychiatry model in the Indian mental health system.

Reorientation of postgraduate training in the background of the Mental Healthcare Act 2017.

In India, postgraduate (PG) training in Psychiatry began in 1941 and came under the regulation of the Medical Council of India in 1956. Since then, it has evolved into a more structured objective system. Most PG courses require compulsory submission of a dissertation work to provide experience in planning, executing, and disseminating research, in addition to clinical work, thus preparing the students to be future teachers or trainers and clinical practitioners. The training regulatory board needs to revisit the curriculum with regard to the provisions under the Mental Healthcare Act (MHCA) 2017, to incorporate the necessary knowledge, skills, and competence of trainees. The Act gives directions to the psychiatrists to act in certain ways in certain situations and makes documentation and completing forms more important. There are provisions for doing research in patients with severe mental illness with certain safeguards. The article discusses the aspects of the MHCA that necessitate modifications to the training, to equip the trainee psychiatrists to work within the framework of the act and also to familiarize them with the aspects of patient safeguards while conducting research. The trainees should take the initiative and put in efforts to understand the practical implications. Mentored learning of practical scenarios in their clinical postings is the best way to learn. Finally, one has to understand that there may be varying interpretations of the provisions of the act. Any interpretation of the provision can still be challenged in court.

Making the most of Mental Healthcare Act 2017: Practitioners' perspective.

The Mental Healthcare Act (MHCA) 2017, after parliamentary approval in 2017, came into effect from May 29, 2018. It is rights-based and empowers the patients to make their own choices unless they become incapacitous due to mental illness. There is much emphasis on the protection of human rights of persons with mental illness. The act provides a framework and regulation on how a person with mental illness should be treated. The experts, on multiple occasions, have debated on whether the act is a boon or a bane for the practitioners in India. The MHCA 2017 brings about more impetus on documentation, unlike the previous acts. With the act in place, clear documentation with reasons for decisions made and care given are important for good practice. Although this may potentially raise the cost of care, this will ensure a safer practice of psychiatry and will prove beneficial for the patients and the psychiatrists. To comply with the provisions of the act, one will have to modify the manner in which one carries out the day-to-day practice. Regular training through workshops is required to understand the practical implications of different provisions of the act. Furthermore, regular peer group meetings may give a sense of support and an opportunity to learn from one another and help find solutions to difficult aspects. Overall, following this and adapting to the new act may bring uniformity in practice. This article aims to explore ways to leverage the MHCA 2017 from the practitioner's perspective.

Civil commitment of persons with mental illness: Comparison of the Mental Healthcare Act 2017 with corresponding legislations of the USA.

The policies and procedures for the treatment of psychiatric patients are within the boundaries of ethical and legal principles of medical practice, with equal importance to human rights and values. Both in India and the USA, the Mental Health Legislation/Act guides psychiatrists in performing their duty toward the patients within this framework. The objective of this review was to compare the Indian Mental Healthcare Act (MHCA) of 2017 with mental health legislations currently existing in the USA, taking New York State Mental Hygiene Law as an example. The evolution of the American mental health legislation over the years was reviewed, including the aspects of involuntary admissions and segregating the psychiatric patients from the community. Over the years, the assessment and treatment approaches inclined toward patient's "rights and liberty" such as assessment of competency to make decisions, the involvement of family members and mandatory requirement of procedure to be followed during admission, inpatient care, and discharge. The current American mental health system is compared and contrasted with MHCA 2017. In the context of existing American mental health legislation and practical issues, this review tried to anticipate possible shortcomings or difficulties that can occur during the implementation of MHCA 2017. Several differences and similarities exist between the two legislations. Added to this, in America itself, there are smaller variations in mental health legislation in each state, albeit the general principles remain the same. Whether this is going to be the case in India once the individual states form the rules is worth a consideration.

The enigma of doctor-patient relationship.

The doctor-patient relationship is crucial to the health-care delivery. In the past, the relationship was viewed as one between a healer and a sick person. However, in the modern era, it is seen as an interaction between a care provider and a service user. The Mental Healthcare Act (MHCA) 2017 gives importance to rights and provision for more autonomy to patients. We examined, in the context of the existing literature, the potential impact the implementation of MHCA 2017 can have on the doctor-patient relationship. A bond between doctor and patient that is based on trust has been an integral part of patient care and has been described to promote recovery, reduce relapse, and enhance treatment adherence. Growing mistrust among patients toward doctors leads them to change their doctors frequently, and due to this, the patients are at risk of losing the therapeutic benefit of the doctor-patient relationship. The doctor-patient relationship has been understudied in areas of health-care need, such as in rural areas, where accessibility and availability of care itself become the most important goal. Medical advancement, with several new treatment options, as well as the availability of many experts for patients to choose from, seems a boon turning into a bane. MHCA 2017 and other health-care policies so far have not given importance to this relationship that is being damaged by several factors including rising health-care costs, especially in private sector and after patients have become "consumers." However, for now, the foremost thing is the psychiatrists have to work to comply with the law and document to justify clinical decisions.

Clinical utility of 18F-FDG-PET/MRI brain in dementia: Preliminary experience from a geriatric clinic in South India.

BACKGROUND: 18F-FDG-PET is a potential sensitive biomarker indicating neuronal damage. 18F-FDG-PET has proven to be useful in subtyping dementia. Utility of simultaneous 18F-FDG-PET and MRI-brain was investigated in the evaluation of dementia in this facility. METHOD: All case notes of patients who underwent 18 F-FDG-PET/MRI brain attending the Geriatric Clinic for 18 month period between January 2017 and June 2018 were retrospectively reviewed. Their socio-demographic details, MRI-brain finding, 18F- FDG-PET findings and comorbid illnesses were studied. RESULTS: A total of 21 patients underwent 18F-FDG-PET/MRI brain during study period. The mean age was 61.23, SD-8.6 years (range: 36-75 years). Among them 5 (23.8%) had Mild Cognitive Impairment (MCI) and 16 (76.2%) had dementia. Majority of patients had early onset cognitive decline (76.2%). Based on the pattern of hypometabolism, the MCI group had one patient each indicative of AD, Semantic-Frontotemporal dementia (Semantic-FTD), mixed Alzheimer's dementia (AD + FTD) and two patients had patterns suggestive of Behaviour Variant of FTD (Bv-FTD). In Dementia group the pattern of hypometabolism was indicative of Bv-FTD in seven, AD in four, Posterior Cortical Atrophy (PCA) in one, Semantic-FTD in one, Mixed AD-Diffuse Lewy Body Dementia (DLBD) in one and no specific pattern in two patients. MRI and 18 F-FDG-PET brain had concordance in 9 (56.26%) patients. DISCUSSION: 18F-FDG-PET/MRI helped in overall clinical diagnosis and management in 19 (90.5%) patients especially with early onset dementia. In MCI group it indicated underlying aetiology and in dementia group it helped in subtyping. CONCLUSION: The study supports the role of 18F-FDG-PET/MRI as an emerging diagnostic tool to assist in dementia evaluation in India.

Implications of Mental Healthcare Act 2017 for geriatric mental health care delivery: A critical appraisal.

The prevalence of mental health problems in older adults is increasing globally as well as in India due to population ageing. Mental Healthcare Act (MHCA) 2017 has a rights-based approach and came into force in India in May 2018. Its provisions have significant implications for promoting mental health care and protecting the rights of persons with mental illness (PMI). Older adults with mental health problems such as dementia have a high risk for loss of mental capacity, abuse, violation of their rights, and institutionalization. This act advocates the development of specialized clinical services for the older adults in mental health care institutions. It also recognizes the rights of PMI to access a range of services required, including rehabilitation services. Several provisions of the act, such as those related to mental capacity, advance directive, nominated representative, and responsibilities of other agencies, have specific challenges related to older adults with mental illness. In this article, we present a critical appraisal of the implications of MHCA 2017 in the context of the care of the older adults with mental illness.

Psychological morbidity after job retirement: A review.

Retirement from work is usually an inevitable and significant social life event for many elderly. The retirement age is generally around 60 years. It can have negative or positive effect in old age depending on other factors such as frailty, slowing cognitive functions, multiple physical health problems, medications and sensory impairment. The objective of the study is to discuss psychological morbidity in persons following retirement in Indian context. Previous studies indicate possible cross-cultural differences with conflicting findings of positive and negative impact on mental health following retirement in the developed countries. Few available Indian studies on this topic suggest lower self-esteem, low mood, physical health and financial insecurity as mental health consequences following retirement. There is need for prospective studies from India to evaluate the impact of retirement on psychological morbidity as well as the role of related social factors, as the effects on mental health post retirement is more likely to be culture specific.

Is there a relationship between Parkinson's disease and obsessive-compulsive disorder?

Obsessive-compulsive (OC) symptoms and obsessive-compulsive disorder (OCD) have been reported in Parkinson's disease (PD). This is interpreted as an indirect evidence for the involvement of frontobasal ganglia circuitry in OCD. However, the evidence for relationship between the OC symptoms and PD is inconsistent. This study systematically assessed OC symptoms and OCD in non-demented idiopathic PD patients (n=69) and matched medically ill controls (n=69). The cases did not differ from controls with respect to OC symptoms, clinical and subclinical OCD, tics and other psychiatric diagnoses. There was no relationship between severity of PD and OC symptoms. The findings do not support relationship between OCD and PD. While the findings of this study do not in any way rule out the involvement of frontobasal ganglia circuitry in OCD, it is speculated that the involvement of different circuitry in the pathophysiology of OCD and PD explain the lack of association between PD and OCD.