Bentley Health Service

BACKGROUND: Recent research has identified several potentially modifiable risk factors for dementia, including mental disorders. Psychotic disorders, such as schizophrenia and delusional disorder, have also been associated with increased risk of cognitive impairment and dementia, but currently available data difficult to generalise because of bias and confounding. We designed the present study to investigate if the presence of a psychotic disorder increased the risk of incident dementia in later life. METHODS: Prospective cohort study of a community-representative sample of 37 770 men aged 65-85 years who were free of dementia at study entry. They were followed for up to 17.7 years using electronic health records. Clinical diagnoses followed the International Classification of Diseases guidelines. As psychotic disorders increase mortality, we considered death a competing risk. RESULTS: A total of 8068 (21.4%) men developed dementia and 23 999 (63.5%) died during follow up. The sub-hazard ratio of dementia associated with a psychotic disorder was 2.67 (95% CI 2.30-3.09), after statistical adjustments for age and prevalent cardiovascular, respiratory, gastrointestinal and renal diseases, cancer, as well as hearing loss, depressive and bipolar disorders, and alcohol use disorder. The association between psychotic disorder and dementia risk varied slightly according to the duration of the psychotic disorder (highest for those with the shortest illness duration), but not the age of onset. No information about the use of antipsychotics was available. CONCLUSION: Older men with a psychotic disorder have nearly three times greater risk of developing dementia than those without psychosis. The pathways linking psychotic disorders to dementia remain unclear but may involve mechanisms other than those associated with Alzheimer's disease and other common dementia syndromes.

OBJECTIVE: Though antipsychotic polypharmacy (APP) is widely utilised in many clinical settings for the treatment of people with schizophrenia, the extent of this practice varies considerably between different regions, countries and clinical settings. Studies from Australasia exploring the prevalence and factors associated with APP are sparse and have yielded inconsistent results. METHODS: We conducted a systematic retrospective audit of the medical records of all admissions in 2010 in the adult wards of a metropolitan public mental health service in Western Australia, having a diagnosis of schizophrenia or schizoaffective disorder. We analysed the rates of APP use, and its association with selected demographic and clinical variables. RESULTS: The prevalence of APP among our sample of 229 patients was high, at 43.2%. APP was associated with a longer hospital stay (p=0.033) and voluntary admission (p=0.027); but APP was not significantly related to: age, gender, diagnosis and treatment by different psychiatrists. CONCLUSIONS: Substantial difference exists between everyday clinical practice and recommendations of practice guidelines of schizophrenia, regarding the use of APP. Prospective studies from different settings exploring the relevant clinical, patient, prescriber and system-related issues are warranted, to comprehend the rationale behind high utilisation of APP in clinical practice.

The use of a parent questionnaire to identify speech and language impairments in 5-year-old children in Western Australia was measured against a speech and language screening assessment performed by a speech-language pathologist. In addition, an identification and referral package containing information on speech and language behaviour and a Teacher Check-list was devised for preschool teachers and piloted with the same population. The comparative clinical usefulness of the parent and teacher tools in identifying those children who had a moderate-severe impairment rather than a mild problem was examined. The value of using teachers as a second order screen, thereby assisting in prioritising children identified through the parent tool, was also investigated. Results showed that, while the parent tool identified a high percentage of children with moderate-severe impairments, clinical utility was undermined by the high over-referral rate resulting in long waiting lists and non-differentiation between mild and moderate-severe impairments. Despite a lower return rate, the teacher tool, when analysed independently of parent data, identified a similar number of children with moderate-severe impairments and had a lower over-referral rate. When the teacher Check-list was used as a second order screen and teacher data analysed only in the event of positive parent identification, the overall effectiveness of the screening process was reduced. Clinical implications are discussed and recommendations made to maximise early identification of communication impairments in preschoolers.

OBJECTIVE: Low endogenous sex hormones and low physical activity (PA) levels have been associated with CVD risk. Whether these interact to influence CVD outcomes remains unclear. We assessed whether sex hormone concentrations and PA were additively associated with lower central adiposity and CVD risk. PATIENTS: 3351 community-dwelling men, mean age 77 years. MEASUREMENTS: Baseline testosterone (T), dihydrotestosterone (DHT) and oestradiol (E2) were assayed. Levels of PA were ascertained by questionnaire. Men were stratified using median splits into high hormone + high PA (H/H), high hormone + low PA (H/L); low hormone + high PA (L/H) and low hormone + low PA (L/L) groups. RESULTS: A total of 865 CVD events and 499 CVD deaths occurred during 10-year mean follow-up. Men with higher T, DHT or SHBG and higher PA had the lowest BMI, waist circumference and risk of metabolic syndrome. Men with higher T had the lowest risk of incident CVD events, irrespective of PA level. Men with higher T or DHT and higher PA had the lowest risk of dying from CVD (eg, hazard ratios for T/PA H/H 0.76 P = 0.031; H/L 0.85 P = 0.222; L/H 0.80 P = 0.075; L/L 1.00). CONCLUSION: Higher circulating androgens and higher PA were associated with less central adiposity at baseline and fewer CVD deaths during follow-up. These findings are consistent with a potential additive effect of androgens and PA on cardiometabolic outcomes in older men.

OBJECTIVE: The purpose of this study was to systematically review the literature relating to the neuropsychiatric symptoms at presentation and outcome of childhood brain tumours. METHODS: Seven online databases pertaining to the neuropsychiatric presentation and outcomes of childhood CNS tumours were searched and PRISMA guidelines were followed. Temporal limits were not applied to the searches. RESULTS: There were 1879 relevant search results in total. After discovering the large body of both primary and secondary research in the field of cognitive and neuropsychological outcomes of brain tumours in children, these studies were excluded. Quality-of-life studies were excluded for the same reason. Thirty-one papers were chosen for discussion in this review. CONCLUSION: This timely systematic review concluded that neuropsychiatric presentations are common in children with CNS tumours-with the presence of behavioural and psychological symptoms in up to 57% of cases, their frequency varies according to age of onset and is strongly associated with time since diagnosis. The findings highlight the necessity for routine psychological and psychiatric screenings of children with suspected brain tumours and at follow-up and a number of clinical recommendations to this effect are listed.

OBJECTIVE: We describe a system of outcome evaluation for early psychosis programmes and present preliminary data. The Early Psychosis Outcome Evaluation System (EPOES) was designed for use in a naturalistic, prospective study of a cohort of early-episode psychosis patients. We describe patients in terms of symptoms, substance use, social functioning and family burden, and examine the effectiveness of treatment programmes. METHOD: Four sites in Perth, Western Australia, participated. Outcome was evaluated from three sources: case manager (CM), patient (P) and family member (FM). Seven clinical outcome measures were used: the Brief Psychiatric Rating Scale (CM), Brief Symptom Inventory (P), Substance Use (CM); Social Functioning Scale (P); Global Assessment Scale (CM); Burden Assessment Scale (FM), and the General Health Questionnaire-12 (FM). Measures were collected at intake (baseline) into a specialist early psychosis service and thereafter every 6 months until discharge from the service. RESULTS: After the first year of data capture, 84 baseline assessments have been completed, and 23 patients have been followed up at 6 months. Clinicians and patients reported significantly less psychopathology at 6 months. Sixty per cent of patients reported marijuana use within 3 months of baseline assessment, and 30% amphetamine, ecstasy or cocaine use. Increased levels of psychopathology were recorded for substance-using patients. Family members (59%) reported psychological distress at baseline; this was reduced at 6 months. Patient social functioning and family burden did not improve measurably. CONCLUSIONS: The EPOES is an effective system that provides feedback on the clinical status of early-episode psychosis patients. Both observed and self-rated psycho-pathology and family psychological distress, is improved after 6 months of intervention. Family burden and patient social functioning did not demonstrate improvement. Patient social functioning is an important area for treatment. Substance use is associated with poorer psychopathology. EPOES provides a feasible system of measuring outcome in early psychosis intervention.

INTRODUCTION: Both type 2 diabetes mellitus (T2DM) and schizophrenia are known to be associated with cognitive deficits. The impact of the comorbidities of T2DM or prediabetes (PD) on cognition among people with schizophrenia has been poorly researched. We evaluated the cognitive functioning of patients with schizophrenia and PD or T2DM and compared them to patients with schizophrenia with normal blood sugar. METHODS: We retrospectively collated data on cognition, fasting blood glucose (FBG), lipids and other selected demographic and clinical variables of 171 patients with schizophrenia and 16 patients with schizoaffective disorder who were admitted to an inpatient rehabilitation facility in Western Australia from 2011 to 2018. The Brief Assessment of Cognition in Schizophrenia (BACS) was used to evaluate cognitive functioning. Parametric and non-parametric analyses were used to examine the study's aims. RESULTS: Sixty-six percent of the patients had normal blood sugar, 25% had PD and 9% had T2DM. The BACS composite score revealed an increasing gradient of cognitive deficits, ranging from mild to severe, between the normal, PD and T2DM groups, respectively. The T2DM group had a significantly lower composite score compared with the PD (p = 0.026) and normal groups (p < 0.001). On the BACS subtests, the scores of T2DM and PD patients were similar except for the token motor task, in which the T2DM group had significantly lower scores (p < 0.001). The T2DM group also had lower scores on the subtests of BACS, except memory tests, compared with those with normal blood sugar. There was no significant difference in the composite and subtest cognitive scores between the PD and normal groups. CONCLUSIONS: Our study revealed more pronounced cognitive deficits among patients with schizophrenia and dysglycaemia, particularly those with T2DM, compared with those with schizophrenia with normal blood sugar.

OBJECTIVE: To determine if hearing loss is associated with increased risk of incident psychosis in later life. METHODS: Longitudinal cohort study of a community-representative sample of 38 173 men aged 65 to 85 years at the start of the follow-up period of 18 years. We used the Western Australian Data Linkage System to ascertain the presence of hearing loss and of psychotic disorders according to the International Classification of Diseases (ICD) (versions 8, 9, and 10). We also collected information on concurrent morbidities: cancer and diseases of the cardiovascular, respiratory, digestive, and renal systems. RESULTS: One thousand four hundred forty-two (3.8%) and 464 (1.2%) men had a recorded diagnosis of hearing loss and psychosis at the start of follow-up. After excluding the 464 participants with prevalent psychosis, 37 709 men were available for the longitudinal study, and of these, 252 (0.7%) developed a psychotic disorder. Competing risk regression showed that hearing loss was associated incident psychosis (subhazard ratio = 2.03, 95% CI, 1.24-3.32; after statistical adjustment for age and concurrent morbidities). CONCLUSIONS: Hearing loss is associated with double the risk of incident psychosis in older men. Available evidence suggests that this link could be causal, although conclusive evidence is still missing from randomized controlled trials designed to test the effect of correction of hearing loss on the prevalence and incidence of psychosis.

John, Alexander Panickacheril FRANZCP; Adriana, Sitha MBBS; La’Brooy, Julia Anne BHSc; Piepiorka-Sokolowska, Danuta MBBS Author Information

OBJECTIVE: The proportion of patients who recommence clozapine after cessation, the time taken to resume clozapine post-cessation, and distinguishing demographic and clinical characteristics of this group have been poorly researched. We evaluated these in the current study. METHOD: We retrospectively extracted selected demographic and clinical variables and clozapine treatment interruption and recommencement data up to December 2018 of a cohort of 458 patients who first commenced clozapine between 2006 and 2016. The study was conducted at three Australian health services. RESULTS: Of the 310 (69%) patients who had at least one interruption of clozapine treatment, 170 (54.8%) did not resume clozapine, and 140 (45.2%) recommenced it after the first interruption. More than half of those who recommenced did so within a month and 80% by 12 months. Cox regression analysis revealed that age was significantly associated with recommencement, with a 2% decrease in the likelihood of restarting after an interruption for each year later that clozapine was initially commenced (HR = 0.98 95%CI: 0.97, 0.997, p = 0.02). Those who ceased clozapine due to adverse effects were less likely to restart than those who ceased due to noncompliance (HR = 0.63 95%CI: 0.41, 0.97, p = 0.03). More time on clozapine prior to interruption increased the likelihood of restarting it, with each additional month on clozapine increasing this likelihood by 1% (HR = 1.01 95%CI: 1.01, 1.02, p < 0.001). CONCLUSION: If the distinguishing demographic and clinical characteristics of the group identified in this study are corroborated through further research, this could further validate the need to identify treatment resistance and commence clozapine early in people with schizophrenia and provide appropriate interventions to those more at risk of permanent discontinuation of clozapine.

Watson, Christopher Mark BA (Psychology), MBBS; Alexander, Aneeka MBBS; John, Alexander Panickacheril MBBS, MD, FRANZCP Author Information

OBJECTIVES: Despite possessing considerable relevance for planning and delivery of effective rehabilitation interventions, systematic evaluation of cognitive function is often ignored in clinical practice. This paper describes a successful method for measuring cognitive function and the nature of cognitive deficits (CD) in people with schizophrenia admitted to psychiatric rehabilitation services. METHODS: Data on the cognitive functioning of consecutive patients with schizophrenia / schizoaffective disorder admitted during a 5-year period to a public in-patient rehabilitation facility was collated retrospectively and analysed. The Brief Assessment of Cognition in Schizophrenia (BACS) was used to evaluate cognitive function. RESULTS: It was possible to administer the BACS to 122 of 135 consecutive admissions. The mean composite score on the BACS was 1.8 standard deviations below the norm, and 43% had moderate or severe CD. The BACS sub-tests of list learning and symbol coding revealed more severe deficits. CONCLUSIONS: The study indicates that evaluation of cognitive function using brief instruments is feasible in psychiatric rehabilitation settings. Global and domain-specific CD were prevalent among people with schizophrenia. In view of the strong association of cognitive functioning with community functioning and rehabilitation outcomes, further studies exploring the feasibility and utility of routinely evaluating cognitive function are warranted.

Described is a case of diffuse large B cell lymphoma that presented within a typical fistula tract, possibly secondary to oxidative stress within the fistula tract itself and consequent malignant change rather than a fistula as a consequence of necrosis in a lymphoma. If so it would be unique in the world literature. A 42-year-old fitness instructor presented with a typical appearing left lateral anal fistula. Biopsy of the fistulous tract revealed B cell lymphoma, graded 1E. Although chemotherapy cured the lymphoma, surgical treatment by ligation of the inter-sphincteric fistula tract was required to heal the fistula. At 3-year follow-up, there has been no recurrence of the lymphoma or the fistula. Neoplasia arising secondary to oxidative stress within an anal fistula is a well-established phenomenon. Early diagnosis of rare conditions associated with anal fistula can only be accomplished by routine biopsy of every fistula tract.

Learning from adverse events and errors is important if systems and processes are to be improved and to minimise the likelihood of similar events in the future. This article uses the report from a coroner's inquest into the death of a seven-year-old child in hospital to examine errors that contributed to the child's death. These errors are reviewed from a human factors perspective. The article provides an overview of error causation concepts and offers strategies that healthcare organisations can implement to reduce the incidence of such errors.

Background The impact of client and programme-related variables on employment outcomes among participants of Individual Placement and Support programmes has been sub-optimally researched. We evaluated the effectiveness of an Individual Placement and Support programme and examined selected demographic, clinical, and programme-related variables associated with obtaining competitive employment. Methods Data were collected retrospectively from consecutive participants with severe mental illness enrolled in an Individual Placement and Support programme co-located as a partnership between a disability employment service provider and a public mental health service in Western Australia. Demographic, clinical, and service engagement characteristics of the groups that obtained and did not obtain competitive employment were collated, compared, and analysed to predict successful employment outcomes. Results Of the 84 participants, 36 (42.9%) secured competitive employment. The absence of psychiatric comorbidity ( p = .037) and especially, shorter time between the programme commencement and first face-to-face contact ( p &lt; .001) were strongly associated with positive employment outcome. Conclusion Modifiable participant and programme-related characteristics can significantly impact the outcome of Individual Placement and Support services for people with severe mental illness implemented at everyday clinical settings. Managing these within clinical services and Individual Placement and Support programmes has potential to improve participant outcomes.

Cognitive deficits (CD) in schizophrenia are recalcitrant to treatment as usual. Whilst there has been considerable interest in recent years for evaluating the efficacy of cognitive remediation (CR) programs in schizophrenia at research settings, scant attention has been paid to evaluate the effectiveness of CR programs at everyday clinical practice settings. Method: We evaluated retrospectively short-term cognitive, occupational and accommodation outcomes of consecutive patients with schizophrenia admitted over a 5 year period at a tertiary-care inpatient public psychiatric rehabilitation facility in Western Australia. The Brief Assessment of Cognition in Schizophrenia (BACS) was utilised to assess cognition. Patients were divided into 3 groups based on their participation in the neuroplasticity based auditory CR program of PositScience; those who did not participate (non-trainers), those who completed less than 20 hours of training (incomplete-trainers) and those who completed 20 or more hours of training (complete-trainers).

<h3>Background</h3> Emerging evidence supports the use of Expiratory Muscle Strength Training (EMST) to treat swallowing, speech, and voice disorders in neurological conditions. Interventions in Huntington’s disease (HD) are limited. The COVID-19 pandemic limited in-person interventions, so this study assessed the efficacy of EMST in HD and telehealth service delivery. <h3>Case history</h3> A 75-year-old male with mid-stage HD, a history of aspiration pneumonia requiring hospital admission, and left subdural haematoma managed with burr hole surgery trialled EMS T. P1 transitioned to L2 mildly thickened fluids 12 months prior to intervention. A single pre- and post-intervention case study used the Repetitive Saliva Swallow Test, Swallow Quality of Life scale, maximum expiratory pressure (MEP), and an unstandardised Timed Water Swallow Test with L2 mildly thickened fluids. Videofluoroscopy (VFSS) was conducted pre-intervention and at week 14. Five EMST sessions were conducted per week for five weeks with follow-up at week six. The 12-week maintenance phase was abandoned after P1 developed unrelated elevated intraocular pressure. <h3>Conclusions</h3> EMST was efficacious in a highly motivated individual with HD, but telehealth delivery was inadequate. A support person is recommended to maintain compliance and manage device calibration. MEP improved from 52.5cm H20 to 60cm H20. Swallows per minute reduced; 12 to 9. Mean seconds-per-swallow reduced; 5.33 to 2.64. Subjective improvements were reported for cough strength, breath support control, confidence at mealtimes, and reduced drooling. VFSS showed improvement and recommended upgrading to L0 thin fluids. Future research should include a randomised controlled trial and validation of assessment tools across HD stages.

Hip fracture is a common cause of morbidity and mortality in the elderly. The major risk factors for femoral fracture are osteoporosis and falls. External hip protectors have been devised which divert direct impact away from the greater trochanter during falls from standing height. Initial studies suggest that these protectors are effective in the prevention of hip fracture, but compliance rates are variable (Lauritzen et al. Lancet 1993; 341: 11-13). The aim of our study was to determine compliance in wearing hip protectors in elderly Dorset rest home residents. 31 rest homes agreed to participate. 288 females were approached and 141 (age 64-98 years) gave informed consent of which 101 were allocated to the intervention arm. Each subject was fitted with 3 pairs of protector pads (Sahvatex, Denmark) sewn into specially designed undergarments. Fortnightly random visits were made to each subject to assess compliance for 12 weeks. 27 subjects wore the hip protectors for the whole study period, and 7 subjects withdrew from the study owing to hospital admission or moving away. 54 subjects wore the pads for less than a week. Approximately one third of participants stopped wearing the hip protectors due to discomfort or poor fitting. Other reasons for non-compliance included illness, physical difficulties (such as incontinence or severe arthritis) and poor memory. In conclusion approximately 50% of elderly rest home residents who are able to give informed consent would wear hip protectors in order to prevent hip fracture, but in the long-term compliance would probably drop to about 30%. Compliance could be increased substantially if the pads and undergarments were modified to enhance their fit and reduce the discomfort associated with their use.

Background Given the robust association of cognitive deficits (CD) with community functioning in people with schizophrenia and the inconsistent findings from the limited research on CD among people with treatment-resistant schizophrenia (TRS), we evaluated the neurocognitive functions of patients with TRS. Methods We retrospectively collated data on cognition and selected demographic and clinical variables of 181 patients with TRS and 59 with treatment-responsive schizophrenia (non-TRS) admitted to a psychiatric rehabilitation facility from 2010 to 2019. The Brief Assessment of Cognition in Schizophrenia (BACS) was used to evaluate cognitive function. Multivariate analysis was utilised to compare the BACS scores of the two groups. Results TRS patients had more severe CD than non-TRS patients, with the BACS composite score ( p = .003), verbal memory and learning ( p = .003), working memory ( p = .043), and psychomotor speed ( p = .004) significantly worse in the TRS group. There was no significant difference in the BACS scores between the 60% of the TRS patients who were treated with clozapine and the TRS patients (40%) treated with other antipsychotics. Conclusion CD are more severe among patients with TRS than in non-TRS cohorts. The pathophysiology of CD among people with TRS and efficacy of interventions to ameliorate CD among this cohort warrant greater scrutiny.

BACKGROUND: Fatigue and attentional decline limit the duration of many therapy sessions in older adults poststroke. Transcranial direct current stimulation (tDCS) may facilitate participation in rehabilitation, potentially via reduced fatigue and improved sustained attention poststroke. OBJECTIVE: To evaluate whether tDCS results in an increase in the number of completed rehabilitation therapy sessions in stroke survivors. METHODS: Nineteen participants were randomly allocated to receive 10 sessions of 2-mA anodal (excitatory) tDCS, or sham tDCS, applied to the left dorsolateral prefrontal cortex (DLPFC) for 20 minutes within 1 hour prior to the first rehabilitation therapy session of the day. After a 2-day washout period, participants then crossed-over. Researchers applying the tDCS, and those recording measures were blinded to group allocation. The number of first rehabilitation therapy sessions completed as planned, as well as the total duration of rehabilitation therapy, were used to determine the influence of tDCS on participation in stroke rehabilitation. RESULTS: = .31). CONCLUSIONS: Our results suggest that, while tDCS to the DLPFC was well tolerated, it did not significantly influence the number of completed rehabilitation therapy sessions in stroke survivors.