Thursday, September 22, 2011

Stress in the festival season

festival time
Festivals as a source of stress? Festivals are meant to be a time of happiness, enjoyment and family togetherness. However for some it can be time of great stress and can adversely affect mental health. The extended festival season starts around Independence Day (15th Aug) and extends right up to New Year including Ganesh Chathurti, Dusshera, and Diwali. Vacations have a positive effect on well-being. However, these effects fade soon after resumption of work (de Bloom 2009). These four months of celebration are associated with psychological distress and mental health problems for many individuals and their families.

Festival distress

(Harion 2009)
Expectations take their toll on the family. Festivals are a prime time for couples to come in for counselling with relationship problems, problems with in-laws, siblings and their children. 'Don't we get to celebrate at least once in our own home?". They end up celebrating each in their own parental homes at Pune and Ahmedabad.

For those in the workforce it means negotiating and competing with everyone else for leave or being the only one left in the office. No one at home understands why you cannot get leave. No one understands why work-pressures and deadlines increase in the time leading up to the holiday. Financial stress also comes into the picture; cool electronics, gifts, partying and vacation trips cost.

For people with mental health problems festivals are another source of stress. Well intentioned, though ill informed relatives prevail on them to stop their medications 'they are addicting', 'why do you need to take them if you're allright?' Many are coaxed into stopping medications entirely.They relapse some time after they return to work, when the social supports are at a minimum and the beneficial effects of the vacation begin to wear off. That is also the time when they have to start paying out the EMIs. This time lag to relapse after stopping psychotropic medication is a prominent factor in non-adherence. 'But he was allright at home. It's the job that is causing stress; we are thinking of relocating'.

Fasting and sleep deprivation are associated in the run up to the festivities. In vulnerable people, especially those with mental health problems, these can play havoc with the body rhythm and with medication regimens leading to a relapse. Every religion excuses ill followers the rigours of these rituals, yet the very people who should be supporting moderation often goad their vulnerable members to comply. 'I thought he was just being lazy'.

Alcoholism is another problem that is likely to recur. It starts insidiously at the beginning of the festival season. By the time the season ends its time for another stint of 'deaddiction'. Binge drinking at parties is just another problem that requires to be addressed recurrently.

Violence and injuries in the home occur through the combination of excitement, stress, tiredness and alcohol. Pressures lead to conflict and then violence. Domestic abuse is about one-third more likely on the day of the festival than the daily average. Homicide rates are generally higher on all major holidays.

Loneliness and isolation are particular issues at festivals. The holiday season is the time of the year when our desire for social contact is most likely to outstrip what our circumstances will allow; it is into this gap that loneliness creeps (Lancet 2010). As festivals are associated with friends and family, it can be difficult for those on their own to avoid feeling lonely at this time. This is especially so for older people living alone who may have no one to spend the festive season with. The loneliness felt on the festival day is often the worst. Festivals can be a sad and nostalgic time, when the loss of a family member may become especially painful. It is often a difficult time for bereaved people. The rates of suicide are known to increase especially on New Years Day (Bridges 2004).

What to do?

Prior to the festival
  1. Communicate. Make your festival plans keeping your spouse in mind. If there were problems  last year don't expect them to disappear. ' I thought we agreed on that last year'. Putting off the discussion could ruin your festivities.
  2. Collaborate. Work together to find a solution that satisfies the needs of all parties. You may not get everything you want, but you get enough of what you want to feel satisfied. Colaboration requires respect for the needs of the other party, communication skills, patience, and creativity. Parties usually do better when they collaborate than when they compete.
  3. Watch the finances. Budget for the expenses and keep a track.
During the festival
  1. Limit your alcohol. Don't drink if you don't want to.
  2. Keep to your normal sleep-wake schedule as far as practicable. When it is disrupted return to your normal schedule at the earliest. Take some time out for exercise.
  3. Take some time off for just yourself and your family. A walk, movie or meal away from the others will contribute to a few more days of harmony.
  4. Your medication is sacrosanct. Don't negotiate on this.
Strategies for loneliness
(Masi 2010)
  1. Improve social skills: After relying on a partner to share experiences and thoughts a separation, breakup or bereavement requires relearning of skills needed to build new relationships and participate in community functions.
  2. Enhance social support: Find a listening ear – people who are lonely can find it helpful to speak to a counsellor or someone removed from their situation.
  3. Increase opportunities for social contact: Be a volunteer – many charities and organisations need help at festivals and you could spend a few hours working as a volunteer. The absence of close family need not be the end of companionship. 
  4. Address maladaptive social cognition: Loneliness can also be tackled by helping people to feel happier in their own company.
    • 'Everyone else is having a good time'. Keep busy – try to stop the festival taking over your life. Make time for enjoyable activities, such as reading, walks, joining a social club or going for a movie.
    • 'What's the point, I'm just not up to it'. Take some physical exercise – this reduces stress and enhances mood. Just getting off the sofa and getting outside should improve mood.
  5. Visit an older neighbour who lives alone if you have a little spare time on your hands over the holidays; it might be just what they need to make their holiday a happy one. 
  1. Bridges SF. Rates of homicide and suicide on major national holidays. Psychological Reports, 2004,94,723-724.
  2. de Bloom J, Kompier M, Geurts S, de Weerth C, Taris T, Sonnentag S. Do we recover from vacation? Meta-analysis of vacation effects on health and well-being. J Occup Health. 2009;51(1):13-25. Epub 2008 Dec 19.
  3. Hairon N. How christmas festivities and pressures can damage health and well-being. Nurs Times. 2008 Dec 16-2009 Jan 12;104(50-51):33-4.
  4. Masi CM, Chen HY, Hawkley LC, Cacioppo JT. A meta-analysis of interventions to reduce loneliness. Pers Soc Psychol Rev. 2011 Aug;15(3):219-66. Epub 2010 Aug 17.
  5. No authors listed. Tackling loneliness in the holidays.Lancet. 2010 Dec 18;376(9758):2042.

Thursday, September 15, 2011

Diagnosing Alzheimer's Dementia

Alzheimer's Disease amyloid plaques and neuro-fibrillay tangles in brain tissue
Microscopic picture of the brain showing amyloid plaques and
 neurofibrillary tangles first seen by Alois Alzheimer in 1907

The diagnosis of Alzheimer's disease became headline news when the defence counsel of a prominent citizen of  Pune stated they were awaiting results of his brain MRI to finalise the diagnosis of dementia. Recently a patient's medication was stopped when his neuro-physician declared there were 'no plaques on MRI so it is not a case of Alzheimers'. The caregivers returned to me when his behaviour problems recurred.

Dementia including that of the Alzheimer's type is a clinical diagnosis (Grand 2011). Dementia is characterised by a triad of
  1. Progressive deterioration of mental processes (cognitive abilities)
  2. Behavioural and psychological symptoms of dementia (BPSD)
  3. Difficulties carrying out day-to-day activities (activities of daily living or ADL).  
Alzheimer's Disease is commonest dementia after 65 years of age Alzheimer's dementia has an insidious onset, and progresses gradually and inexorably. This natural course is a key differentiator Alzheimer's from other forms of dementia. Dementia is suspected when a caregiver of an elderly person, or sometimes a person with a family history of dementia, becomes concerned about problems with memory. The diagnosis is purely clinical. No laboratory test or imaging (including MRI) is required to diagnose Alzheimer's disease. These investigations can only help differentiate the other forms of dementia when those are suspected.

Memory problems are a core feature of the disease. These manifest as
  • Difficulty recalling details of recent events (forgets he has already dropped his grandchild to school), personal conversations, or specific elements of a task she is performing (eg, preparing a meal)
  • Asking the same question multiple times while denying repeated questioning
  • Tendency to make up events to fill memory gaps and to give inaccurate responses to questions (what he had for breakfast)
Other common cognitive concerns that could indicate dementia of the Alzheimer or any other type
  • Disoreintation to time and place. As the illness progresses orientation worsens to include problems identifying familiar places, family members, or other well known people.
  • Difficulties with activities of daily living (ADL). Problems with dressing or using common utensils
  • Language impairments resulting in decreased conversational output, word-finding difficulties, and limited vocabulary.
  • Visuo-spatial dysfunction manifest as impaired driving ability, and getting lost
  • Problems with mathematical calculations impair ability to use money and balance finances.
  • Impaired judgement in novel situations (difficulty planning a vacation).
Behavioural and psychological symptoms (BPSD)
  • Depression occurs in up to 50% of individuals with Alzheimer's Dementia, and may be attributed to awareness of cognitive changes
  • Lack of feeling or emotion (apathy) is associated with significant caregiver distress
  • Psychosis generally occurs later in the disease course. Delusions are predominantly paranoid in nature, with fears of personal harm or mistreatment, theft of personal property (usually related to financial matters), and marital infidelity. Hallucinations are less common than delusions, and tend to be visual.
  • Other behavioural symptoms include agitation, wandering, and sleep disturbances.

Diagnosis of Alzheimer's Disease is based on 
  1. Detailed history to identify memory deficits, and other cognitive symptoms and assess their impact on the individual and family.
  2. A thorough clinical exam (mental status examination) confirms the impairments in memory and cognition, and delineates the behavioural and psychiatric symptoms that cause caregivers concern. This usually includes using validated and standardised screening pencil and paper tests. 
  3. Psychological testing confirms and quantifies the impairments across various areas of brain function (memory, language, visuo-spatial), assesses the treatment response, and documents progression of the illness with time.

Laboratory tests including MRI only differentiate Alzheimer's disease from other disorders such as subdural haematoma, brain tumour, hydrocephalus, and dementia associated with vascular disease. Magnetic Resonance Imaging (MRI) has no other clinical utility in Alzheimer's disease. These tests are not required or mandated by any classification system including that of the WHO (ICD) or the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA).

Amyloid plaques, and neurofibrillary tangles are the hallmark of Alzheimer's disease and are required for a definitive diagnosis. These were first discovered by Alois Alzheimer in 1907.  His slides were rediscovered in 1992 and 1997. The rediscovered images show the classical pathological signs of the disease named after him. Amyloid plaques and neurofibrillary tangles are seen on microscopic examination of brain tissue using special staining techniques or by electron microscopy. Therefore the only way to obtain a definitive diagnosis of Alzheimer's disease is to obtain a brain tissue sample by biopsy or on autopsy. No MRI, however advanced can detect plaques.
For the purpose of treatment a probable diagnosis using bedside techniques of history and clinical examination is all that is required to diagnose Alzheimer's disease.

  1. Dickerson BC. Advances in quantitative magnetic resonance imaging-based biomarkers for Alzheimer disease. Alzheimers Res Ther. 2010 Jul 6;2(4):21.
  2. Graeber MB, Kösel S, Egensperger R, Banati RB, Müller U, Bise K, Hoff P, Möller HJ, Fujisawa K, Mehraein P. Rediscovery of the case described by Alois Alzheimer in 1911: historical, histological and molecular genetic analysis. Neurogenetics. 1997 May;1(1):73-80.
  3. Grand JH, Caspar S, Macdonald SW. Clinical features and multidisciplinary approaches to dementia care. J Multidiscip Healthc. 2011;4:125-47. Epub 2011 May 15.
  4. McKhann G, Drachman D, Folstein M, Katzman R, Price D, Stadlan EM. Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology. 1984 Jul;34(7):939-44.

Thursday, September 8, 2011

Parental supervision of children and adolescents

parental supervision and injuries in children with high intensity behaviour
Parental supervision protects boisterous children from injury:
More time unsupervised corresponds to more injury 
“To my parents we were just two girls in the bedroom”. What exactly was going on? Without adequate supervision the parents of this teenager never found out; the memories returned to haunt her in adulthood. Studies comparing children with and without parental supervision show that lax parental supervision is associated with injury in toddlers and preschoolers; conduct problems in school going children; and road accidents, addictions, gambling and sexual risk taking in teenagers.

Parental supervision has three dimensions (Gitanjali 2004)
  1. Attention - watching or listening 
  2. Proximity - within or beyond reach 
  3. Continuity - constant, intermittent, or not at all 

Two factors determine the degree to which a child would be left unsupervised (Morrongiello 2008)
  1. Parent’s conscientiousness - the more conscientious the parent more the supervision
  2. Child’s propensity for risky behaviour - the more impulsive and sensation seeking the child the more likely the child will be kept in direct view. 

Distinguishing adequate from neglectful supervision is not straight forward. The consequences of lower levels of supervision are not uniform for all children. The consequences depend to a great extent on child attributes. For children with high sensation seeking, even close supervision is not adequate to prevent injury. For children who are high in behavioural control, even not supervising does not elevate risk of injury.

Whether or not children comply with their parents’ requests to behave in safe ways is a complex interaction of parenting style, attachment style,  and child temperament. The level of supervision necessary to ensure a child’s safety should finally be based on the child’s characteristics. The only reliable maxim is that the time children could be safely left unsupervised generally increases with child age.

Parental supervision of an adolescent differs from supervising a younger child (DeVore 2005). Direct parental observation gradually gives way to indirect parental ‘‘monitoring’. This indirect supervision involves ongoing communication between parents and adolescents about the adolescents’
  • Whereabouts
  • Friends they are with
  • Schedule to return home
  • Contact information enabling parents to directly communicate with adolescents. 
Effective supervision entails active participation of the adolescent, and honest communication between adolescent and parents.

Parental monitoring buffers negative peer influence. Strong peer attachments and increasing independence from the family is a normal part of adolescent development. Unfortunately, youth whose peers engage in high-risk behaviour are at high risk for the development of similar behaviours. Not only are high levels of monitoring protective, low levels of parental monitoring have been associated with numerous risk behaviours.

More unsupervised time is associated with more sexual activity in youth (Cohen 2002). In one urban study more than half of sexually active youth had sex at home after school. For boys, sex and drug-related risks increase with amount of unsupervised time. Trust and communication did not predict decreases in problem behaviour as strongly as did monitoring. Parental monitoring may be particularly protective for high-risk young urban adolescents; those who spend a significant amount of non-school time unsupervised. 

  1. Cohen DA, Farley TA, Taylor SN, et al. When and where do youths have sex? The potential role of adult supervision. Pediatrics 2002; 110:e66 
  2. DeVore ER, Ginsburg KR. The protective effects of good parenting on adolescents. Curr Opin Pediatr. 2005 Aug;17(4):460-5. 
  3. Gitanjali S, Brenner R, Morrongiello BA, Haynie D, Rivera M, Cheng T. The role of supervision in child injury risk: Definition, conceptual, and measurement issues. Journal of Injury Control & Safety Promotion 2004;11(1):17-22. 
  4. Morrongiello BA, Klemencic N, Corbett M. Interactions between child behavior patterns and parent supervision: Implications for children’s risk of unintentional injury. Child Development 2008;79(3):627-638.