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Among the one million suicide deaths worldwide each year, as many as 60% occur in Asia. The World Health Organization (WHO) found higher suicide rates among the elderly in rapidly industrialized Asian countries such as China, Hong Kong, Japan, South Korea, Malaysia, and Singapore, compared to the corresponding rates of recently industrializing Asian countries like Vietnam and Sri Lanka (WHO, 2014). As a case in point, suicide rates in South Korea have been the highest in the world since 2003 and are rising especially among older people (Hong and Knapp, 2014). Suicide attempts and older age are strong predictors of completed suicide (Szanto et al., 2002; Simon et al., 2013) and, as such, are important in guiding our efforts for suicide prevention; however, most epidemiological studies focus on completed suicides across all ages rather than understanding the reasons behind suicide attempts in older populations.
Delirium significantly increases morbidity and mortality in older people, especially those affected by other organic disorders, notably dementia (Siddiqi et al., 2006; Davis et al., 2012; Martins and Fernandes, 2012). Both delirium and dementia are characterized by cognitive decline through disintegration of brain functions, i.e. a “brain failure.” Delirium has been described as an acute brain failure, in contrast to dementia being a chronic brain failure (Berrios, 1981). If we consider any other organ failure, for example that of kidneys, delirium superimposed on dementia resembles acute renal exacerbation superimposed on chronic renal failure. The timely recognition and treatment of acute renal failure can reverse its damaging effects, whereas chronic renal failure necessitates long-term and invasive or costly interventions (i.e. dialysis, kidney transplantation). Similarly, recognizing delirium and providing timely interventions can improve its symptoms to recover brain functions, delay cognitive decline, and alleviate distress and disability.
We assessed eight-year mortality rates and predictors in a rural cohort of elderly individuals with cognitive impairment.
A total of 1,035 individuals, including 155 (15.0%) individuals with cognitive impairment, no dementia (CIND), and 69 (6.7%) individuals with clinically diagnosed dementia were followed for eight years from 1997. The initial assessment involved a two-step diagnostic procedure performed during a door-to-door survey, and mortality data were obtained from the Korean National Statistical Office (KNSO). The relationship between clinical diagnosis and risk of death was examined using the Cox proportional hazards model after adjusting for age, sex, and education.
During follow-up, 392 individuals died (37.9%). Compared to persons without cognitive impairment, mortality risk was nearly double among those with CIND (hazard ratio [95% confidence interval], 1.92 [1.46–2.54]), and this increased more than three-fold among those with dementia (3.20 [2.30–4.44]). Old age and high scores on the behavioral changes scale at diagnosis were two common predictors of mortality among those with CIND and dementia. Among the items on the behavioral changes scale, low sociability, less spontaneity, and poor hygiene were associated with increased mortality in individuals with CIND. Conversely, low sociability, excessive emotionality, and irritability were associated with increased mortality in patients with dementia.
Both dementia and CIND increased mortality risk compared with normal cognition in this community cohort. It is important to identify and manage early behavioral changes to reduce mortality in individuals with CIND and dementia.
The growing proportion of older people, their longer survival and their longer period of morbidity and disability, have seen health expenditure increase exponentially, which no government can afford. Pharmaceutical expenditure is an increasingly important part of overall healthcare costs and the growing costs of prescription medicines have become a major burden to health care systems worldwide. Medicines account for 20–60% of health spending in developing and transitional countries, in which some governments consistently pay prices above the international reference prices to procure a number of medicines (Suh, 2011). Owing to the different interests of stakeholders (the pharmaceutical companies, medical professionals, patients and family members) who play a major role in healthcare policy-making, international or national policies for cost-containment are drifting or sometimes take a back seat.
The Korean peninsula is located between China and Japan. After the Second World War, the Republic of Korea was established in the southern half of the Korean peninsula. South Korea has a total area of 98 480 km2 and a population of 48 598 175 (July 2004 estimate). The per capita gross domestic product (GDP), in terms of purchasing power parity, is US$17 700 (2003 estimate) (Central Intelligence Agency, 2004). The illiteracy rate (among those aged over 15 years) is 1.9% (0.7% for males and 3% for females) (2003 estimate). Life expectancy at birth is 75.6 years (72.0 years for males and 79.5 years for females) and the infant mortality rate is 7.2 per 1000 births (2004 estimate). The unemployment rate is 3.4% (2003 estimate). The proportion of the population aged 65 and over is currently 8.7% (2004 estimate) (Korea National Statistics Office, 2003). Over 40% of the total Korean population (i.e. some 20 million) lives in Seoul and its vicinity. South Korea is highly urbanised and modernised. Besides central government, local government is based on seven metropolitan cities and
Mental health services
There is one hospital bed for every 148 citizens and one psychiatric bed for every 1446. There is one physician for 830 citizens and one psychiatrist for every 19 500 (2002 estimates).
The basic healthcare needs of the Korean population are covered by universal public health insurance, funded by premiums, not taxes. This is compulsory, and there is no private health insurance. None the less, the private sector accounts for approximately 90% of mental health services, as there are too few public facilities. However, the government is responsible for free nationwide healthcare funded by taxes for the poor and aged. Thanks to an active community mental health movement in the public and private sector of psychiatry, since 1995, 242 public health centres nationwide have registered to take care of people with mental illness, including elderly people with dementia or stroke. In 2002, there were 989 specialist mental health facilities in South Korea: 46 community mental health centres, 66 social rehabilitation facilities, 74 mental hospitals, 207 general hospitals with psychiatric out-patient departments, 541 psychiatric clinics and 55 nursing homes.
Background: Alzheimer's drugs are believed to have limited availability and to be unaffordable in low- and middle-income countries compared to high-income countries. The price, availability and affordability of Alzheimer's drugs have not been reported before.
Methods: During 2007 an international survey was conducted in 21 countries in six continents (Argentina, Australia, Brazil, the Dominican Republic, France, India, Japan, Macedonia, Mexico, New Zealand, Nigeria, the Philippines, Portugal, Serbia, South Korea, Switzerland, Taiwan, Thailand, Uganda, the U.K. and the U.S.A.). Prices of Alzheimer's drugs were compared using the affordability index (the total number of units purchasable with one's daily income) derived from purchasing power parity (PPP) converted prices as well as raw prices.
Results: Donepezil is available in all 21 countries, whereas the newer drugs are less available. A 5 mg tablet of branded originator donepezil costs just US$0.26 in India and US$0.31 in Mexico, whereas it costs US$6.64 in the U.S.A. Pricing conditions of rivastigmine, galantamine and memantine appear to be similar to that of donepezil. The cheapest branded originators are from India and Mexico. However, in terms of PPP, Alzheimer's drugs in other low- and middle-income countries are much more expensive than in high-income countries. Most people in low- and middle-income countries cannot afford Alzheimer's drugs.
Conclusions: Alzheimer's drugs, albeit available, are often unaffordable for those who need them most. It is hoped that equitable differential pricing will be applied to Alzheimer's drugs.
Higher rates of cerebrovascular adverse events (CVEs) and mortality for dementia patients taking active drugs were reported during industry-sponsored clinical trials of atypical antipsychotics for the treatment of behavioral and psychological symptoms of dementia (BPSD). Since then, the use of antipsychotics for BPSD has not been recommended on the basis of advisory warnings issued by regulatory authorities in several countries. Nevertheless, there are currently no demonstrated pharmacologic alternatives. Although early published and unpublished data indicated a risk, few subsequent publications have supported the initial finding. In order to update earlier comments published in International Psychogeriatrics (Shah and Suh, 2005), this editorial briefly introduces subsequent reports, summarizes the discrepant findings of experimental and non-experimental studies, highlights the effect of “Simpson's paradox”, which causes us to throw doubt on conclusions based on meta-analyses or pooled-analyses, explains this discrepancy in the light of current knowledge, and concludes with practical recommendations regarding the use of atypical antipsychotics in dementia.
Background: This study aims to establish the incidence rates of Alzheimer's disease (AD) and to understand the relations between illiteracy and AD in the Korean Yonchon survey cohort.
Methods: A community-based, dementia-free cohort of 966 people aged 65 years and older was followed up for an average of 5.4 ± 1.60 years to detect incident AD cases using a two-phase procedure. Age-specific incidence rates were calculated using a person-years approach with Poisson distribution confidence intervals. Data were analyzed using the Cox proportional hazards model to find the hazard ratio of illiteracy.
Results: The participating percentage of the survivors was 86.4% and 74 subjects were diagnosed with AD. Incidence rates per 1000 person-years were 20.99 (95% CI 16.48 to 26.35) for AD. The hazard ratio of illiteracy was 1.78 (95% CI 1.08 to 2.93) adjusted for age, sex, educational level. AD developed more rapidly with aging in the illiterate group than in the literate group.
Conclusions: Illiteracy is associated with a higher risk of AD and the risk increases with age.
Technological developments in medicine have conspired to increase costs, not only because they often require more expensive procedures, but also because they increase the size of the patient population who, at least potentially, could benefit from treatment. Health care has been considered a right of citizenship to which every person must have guaranteed equal and unlimited access. However, because of relentless pressure on public health care budgets, health care is now being treated in much the same way as food or housing or pensions – the government simply establishes a guaranteed base level of protection. Economics is about getting better value from the deployment of scarce resources when a choice has to be made. An important purpose of economic evaluation is that it should serve as a tool for decision-making regarding the allocation of scarce resources (Drummond et al., 1997). Cost effectiveness means cutting costs, but not at the expense of less effective outcomes (Mooney and Drummond, 1982). There appear to be lots of mental health issues with health economic implications.
Background and objectives: The use of risperidone or olanzapine to treat behavioral problems associated with dementia is no longer recommended in the U.K. because of the increased risk of cerebrovascular adverse effects (CVAEs) and/or mortality. To evaluate the risks and benefits of antipsychotics, we measured the rate of mortality in patients with dementia, Alzheimer's disease (AD) and vascular/mixed dementia and compared mortality rates between those who had received antipsychotics and those who had not received antipsychotics.
Methods: A total of 273 subjects were assessed at baseline, 6 months and 12 months using a 1-year prospective follow-up design. Mortality rates between groups were compared using a Kaplan–Meier curve and log-rank statistics. Relative risks (RRs) were examined by the Cox proportional-hazards model.
Results: The overall 1-year mortality rate in dementia was 23.8%. The mortality rate in those who had not received antipsychotics (26.8%) was higher than that in those who had received antipsychotics (20.6%). RR and 95% confidence interval (CI) of mortality, when we compared those who had not received antipsychotics with those who had received antipsychotics, was 1.277 (95% CI 1.134–1.437) after controlling for age, severity of dementia, medical comorbidities, cognitive impairment (measured by the Korean version of the Mini-mental State Examination (MMSE)) and behavioral and psychological symptoms of dementia (BPSD), measured by the Behavioral Pathology in Alzheimer's Disease Rating Scale, Korean version (BEHAVE-AD-K). When those who had not received antipsychotics were compared with those who had received both risperidone and haloperidol, RR (95% CI) was 1.225 (1.101–1.364).
Conclusion: This study does not support reports that antipsychotics increase mortality in dementia.
Background: There is a paucity of cross-cultural studies of behavioral and psychological symptoms of dementia (BPSD).
Method: BPSD were examined in consecutive series of referrals to a psychogeriatric service in Korea and the U.K. using the Behavioral Pathology in Alzheimer's Disease (BEHAVE-AD) rating scale and the Cornell Scale for Depression in Dementia (CSDD). Results were analyzed separately for Alzheimer's disease and vascular dementia.
Results: Koreans in both diagnostic groups had lower Mini-mental State Examination (MMSE) scores and higher BEHAVE-AD total and subscale scores for most subscales. In both countries, for both diagnostic groups, the total BEHAVE-AD score and several subscale scores were negatively correlated with the MMSE scores. Logistic regression analysis for Alzheimer's disease revealed that BEHAVE-AD total and most subscale scores independently predicted the country of origin in addition to the MMSE scores predicting the same.
Conclusions: These differences in BPSD are most likely explained by the lower MMSE scores in the Korean sample. However, genuine differences in BPSD between the two countries can only be critically examined in a cross-cultural population-based epidemiological study for both diagnostic categories using validated instruments to measure BPSD and controlling for the influence of MMSE score.
Behavioral and psychological signs and symptoms of dementia (BPSD) include disorders of behavior, mood, thought content and perception (Burns et al., 1990a, b, c, d; Foli and Shah, 2000). BPSD are common (Foli and Shah, 2000) and can cause distress to patients, informal carers and professionals, and lead to institutionalization and over-medication (Shah, 1999). Both non-pharmacological and pharmacological treatment strategies have been utilized to improve BPSD. Despite the recent controversy surrounding the use of olanzapine and risperidone for BPSD, a case for judicious use of these drugs is rehearsed below.
The Korean peninsula is located between China and Japan. After the Second World War, the Republic of Korea was established in the southern half of the Korean peninsula. South Korea has a total area of 98 480 km2 and a population of 48 598 175 (July 2004 estimate). The per capita gross domestic product (GDP), in terms of purchasing power parity, is US$17 700 (2003 estimate) (Central Intelligence Agency, 2004). The illiteracy rate (among those aged over 15 years) is 1.9% (0.7% for males and 3% for females) (2003 estimate). Life expectancy at birth is 75.6 years (72.0 years for males and 79.5 years for females) and the infant mortality rate is 7.2 per 1000 births (2004 estimate). The unemployment rate is 3.4% (2003 estimate). The proportion of the population aged 65 and over is currently 8.7% (2004 estimate) (Korea National Statistics Office, 2003). Over 40% of the total Korean population (i.e. some 20 million) lives in Seoul and its vicinity. South Korea is highly urbanised and modernised. Besides central government, local government is based on seven metropolitan cities and nine provinces.
Background/Objective: There were few studies identifying the natural unfolding of behavioural and psychological symptoms of dementia (BPSD) in the course of Alzheimer's disease (AD) progression in antipsychotic-naïve AD patients. This study aims to examine the specific nature of the association between BPSD in AD and the global severity of illness measured by Global Deterioration Scale(GDS) in antipsychotic-naïve AD patients in Korea.
Methods: A total of 562 antipsychotics-naïve AD patients were recruited from four different groups [a geriatric mental hospital (n=145), a semi-hospitalized dementia institution (n=120), a dementia clinic (n=114) and community-dwelling dementia patients (n=183)]. BPSD exhibited by AD patients were measured using the 25-item Korean version of the BEHAVE-AD.
Results: Ninety-two percent (n=517) of AD patients had at least one BPSD, while 56% (n=315) had 4 or more BPSD. Specific kinds of behavioral disturbance peak at the stages of moderate AD (GDS stage 5) or moderately severe AD (GDS stage 6). AD patients left at home without any treatment had higher frequency of BPSD than did other groups seeking treatment, although all of them were antipsychotic-naïve.
Conclusion: BPSD potentially remediable to treatment were highly frequent in Korean AD patients. Health policies to meet the unmet needs of elderly Koreans are urgently needed, especially for AD patients at home without treatment.
Background: There is a paucity of cross-cultural studies of behavioral and psychological symptoms of dementia (BPSD).
Method: BPSD were examined in a consecutive series of referrals to a psychogeriatric service in the United Kingdom (U.K.) and in Korea, using the BEHAVE-AD, the Cornell Scale for Depression in Dementia and the Mini-mental State Examination (MMSE). The U.K. service served a well-defined geographical catchment area with a multidisciplinary team and emphasis on home assessments. The Korean service was a nationwide service with limited community resources. The correlates of individual BPSD in each country and the differences between the two countries were examined.
Results: Koreans were younger, were more likely to be married, less likely to be single, had a greater number of people in their household and were more likely to live in their own homes than the U.K. sample. Koreans were more likely to be referred by general psychiatrists or family members, and the U.K. sample was more likely to be referred by general practitioners. Koreans were more likely to have Alzheimer's disease and the U.K. sample to have vascular dementia. The Korean sample had a lower MMSE score than the U.K. sample. In both countries, the total BEHAVE-AD score and most subscale scores were negatively correlated with the MMSE score. The total BEHAVE-AD score and all subscale scores were higher in the Korean sample than in the U.K. sample. The prevalence of all BPSD measured with the BEHAVE-AD were higher in the Korean sample (except aggressivity).
Conclusion: These differences may be explained by differing interpretation and administration of the measurement instruments, models of service delivery, availability of primary and secondary care services, health seeking behavior of patients and families, cultural influences, and knowledge, expectations and recognition of BPSD by professionals in primary and secondary care. However, despite this, there was possible evidence of genuine differences worthy of further cross-cultural population-based epidemiological study of BPSD between these two countries.
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