Bilingualism is the ability to communicate proficiently in more than one language. Skills involved include the ability to listen, comprehend, speak, read, and write in a language other than the mother tongue.
Singapore’s Multilingualism
With a few exceptions, the majority of the world’s countries are actually multilingual, and the citizens can speak two or more languages. Singapore boasts of having four official national languages: English, Mandarin Chinese, Malay and Tamil. Unlike other countries’ multilingualism, Singapore’s four official languages are most divergent, because they do not share any recent common evolutionary ancestry. It is often argued that Singaporeans are actually trilingual because many households speak a separate Chinese dialect such as Hokkien, or a different regional Indian language such as Hindi, which is quite unlike the official national languages of Mandarin and Tamil. Over recent decades, English has gained the upper hand, but bilingualism is still prevalent.
Subtypes of Bilingualism
Fundamentally, the brain tackles language in four ways. The initial input is listening, which is followed by the output of speaking. Then later, the input is reading, and the output is writing.
The age at which someone starts to learn a second language can make a difference in the outcome. For example, let’s take a hypothetical family of four who has immigrated to Singapore from a country where they speak a different language, and do not speak any of the four national languages. The family comprises a 3-year old daughter, an 11-year old son, and the parents. There are three subsets of bilingualism which are classified as follows:
a) Compound
The three-year-old has been learning the native language of the parents, and in Singapore, she attends a preschool and is immersed in English. She readily picks up the second language and begins to process the world around her in this language. Her command of English is excellent, and she might even develop a Singlish accent. As time passes, one language might become more dominant. This should not be seen as a problem because there are many benefits in bilingualism (see below). This early childhood form of bilingualism is known as “compound”.
b) Coordinate
The teenage brother speaks his native language, but in Singapore, he has to learn English from scratch, but fortunately he picks it up very quickly. At school he would speak English to his schoolmates, but at home, he might continue conversing in his native tongue. Over the years, he might speak English predominantly. His bilingualism is referred to as “coordinate”.
c) Subordinate
The parents are learning a secondary language but filters it through their primary native language. They sometimes have to think for a brief moment in order to understand what is said, or translate into English to express their thoughts. They may even have a trace of an accent related to their native tongue. This form of bilingualism is known as “subordinate”.
Because many bilingual individuals can become quite proficient in the new language, and barely colour the speech with their native accents or pronunciations, the difference in their speaking may not even be apparent to a casual observer.
The Brain
Multilingual vs Monolingual Brain
How does the brain handle bilingualism? Functional magnetic resonance imaging (fMRI) and positron emission tomographic (PET) scans have shown increased connectivity between the frontal and posterior parts of the brain compared with monolingual people. This means there is enhanced brain activity as well as improved cognitive reserve.
In early childhood, the brain is more malleable than an adult’s and this plasticity allows the developing brain to use both hemispheres in language acquisition. There is increased density of grey matter as well as more activity between the frontal, parietal and temporal lobe areas when engaging in a second language. In contrast, the adult’s brain development when learning a second language is largely lateralised to the left hemisphere.
Monolingual vs Bilingual Brain
The increased activity in a bilingual brain over the years has also been shown to delay dementia, including Alzheimer Disease, by as much as 5 years.
Creole or Pidgin Language
In countries where more languages are spoken, there is a tendency for the speaker to combine two or more languages. This is referred to as creole or pidgin language. This has been classified into 3 degrees of severity:
a) Acrolect: where there is no significant difference between the spoken language from its origins, so listeners have no difficulty understanding.
b) Mesolect: where there are several loan words, plus some dropping of indefinite articles and plural markings on some nouns. Examples of mesolect include “sabo” = “sabotage”, “shiok” = “great” (from the Malay)
c) Basilect: where the combination of words from two or more languages is so severe that foreign listeners have difficulty understanding what is spoken. This is referred to as heavy creole or heavy pidgin. An example is “I buay tahan he talk cock” = “I cannot tolerate his talking nonsense”.
Many speakers of heavy creole or heavy pidgin languages have the ability to switch from this severe form of slang to acrolect or even to the pure speech of the language of origin.
Benefits of Bilingualism
There are many benefits of learning several languages, especially at a very young age. This is backed up by scientific studies, and the bonuses include:
Enhanced mental development
Greater focus, flexibility, problem-solving skills, and creativity
One can order food more easily from hawker centres and food courts
Hawker Centre
Watch movies without subtitles
Delay dementia, including Alzheimer Disease
Maintain contact with family, the older generation, and retain cultural heritage
Fewer racial biases, better multiracial integration, and make more friends
Do more overseas business
Bilingualism is a national policy in Singapore schools, and is therefore compulsory. However, it has come under some criticisms. The problem is that not everyone is good at learning a second language, and some struggle painfully, and suffer. Another problem is that those who are good at learning languages are not encouraged to learn a third language, such as Malay, Korean, Japanese, or an Indian or European language. Learning extra languages can enhance future careers and business entrepreneurship.
Will Modern Technology Discourage Learning Another Language?
Currently there are many devices that can automatically translate spoken words from one language to another. This means that there is no need to learn a foreign language. It is claimed that even culture-specific swear words, jargon, and slang are all translatable. So the question one will ask is: “Why bother learning another language?” The answer is that present-day devices may not be so good in translating the underlying emotions that accompany one’s speech. Subtle subtext can be lost. For example when one says something sarcastic like “You think you are very clever?” it might be translated in a neutral way, so that the listener might take it as a compliment!
Conclusions
Bilingualism is an important ability that has many benefits, including enhancing brain function, communicating with a wider range of people, delaying dementia, and promoting overseas business. The younger a second language is introduced to a child, the better the long-term outcomes. Their command of the second language will be better, and they will be more flexible and creative in their thinking. Although bilingualism does not increase one’s intelligence, it does delay Alzheimer Disease. It has been shown that even if one did not have the good fortune to learn a second language in early childhood, there are still benefits learning one later in life. It exercises the brain, and as the saying goes, even “a little exercise can go a long way!”
Afterthought: Is multilingualism declining worldwide?
The evidence is anecdotal, but the impression seems to be that fewer people worldwide are multilingual. English-speaking countries like the USA are not actively promoting the learning of second languages, and classrooms discourage speaking in a non-English tongue. The second generation of emigrants to these countries barely speak the native languages of their parents.
Which languages are the first to die? Sadly, the first languages to die off are “die”-lects (sorry for the weak attempt at a joke)!
The recent death of a 13-year-old schoolboy allegedly caused by a 16-year-old schoolmate, coupled with the rising rate of suicides, has raised concerns about mental health. The increase in psychological distress in children may be related to the current COVID-19 pandemic. The question is whether we are tackling the problems effectively? If not, why not?
First, let us define what we mean by mental health in children.
Definition (1)
Mental health is the complete well-being of a person, including their emotional, psychological, and social life. This affects how one thinks, feels, and acts. It can determine how one handles stress, interact with others, and make choices.
Child mental health is defined slightly differently from adult mental health; it is more nuanced and multifaceted. In addition to emotional and social aspects of psychological health, there is an additional emphasis on behavioural and cognitive functions. A child has unique developmental milestones and experiences which can affect their mental states and thinking over time. Also they may be less able to express their emotions, or they do so differently, which can be misinterpreted or overlooked. Because children’s mental health is a continuum, stretching from early childhood through adolescence, and going all the way to adulthood, the definition needs to embrace the different emotions and expressions associated with the different stages of life.
Presentation (2,3)
It is often said that children wear their hearts on their sleeves. Certainly, younger children may not be able to hide their feelings very well. Late teenagers’ thinking resemble more like that of an adult’s. It is therefore a challenge for parents and teachers to learn how to decipher a child’s behaviour and figure out their underlying meanings.
Changes in behaviour are still the best clues in assessing mental disorders. If a very outgoing sociable young child suddenly becomes reclusive, refuses to eat, does not want to go to school, or refuses to do what they normally do, then something may be wrong. If they are normally close to their parents and then undergo a massive change in behaviour by becoming inconsistent, or shuns spending time to talk to or hug their loved ones, then it is time to delve a little deeper.
Mental health problems of older children and teenagers may be more difficult to detect because they may look perfectly healthy at first glance, until you look more closely their facial expressions or body language. There are certain societal norms that when crossed, may provide clues to potential behavioural abnormalities. For example, if a child becomes inappropriately happy, sad or angry given the circumstances, this can be a clue. Here is a list of the more common signs and symptoms suggestive of mental health problems:
Heightened sensitivity to sounds, sights, touch, smells
Unusually odd uncharacteristic behaviour
Prevalence (4)
The prevalence of mental health problems in Singapore is around 13.9% which is lower than the global average of 20%, but is nevertheless quite a burden. However, the prevalence has increased during the COVID-19 pandemic.
Psychiatrists have reported an increased number of referrals for mental health issues during the COVID-19 pandemic (5).
Causes
Failing at school tests or exams, scolded by teachers, being bullied at school or cyberbullied on the internet, emotional abuse by friends, can all precipitate mental problems. On top of that, there may be parental conflicts, or other family problems resulting from job losses and reduced financial income. Additional factors include suspension of overseas vacations, limitations of entertainment in cinema and theatre because of reduction in seating capacity, inability to dine out with larger numbers, have added further to mental stress.
Neurodevelopmental Causes
What causes mental health impairments? Twenty-first century science is exploring the answers at a molecular level, where genetics play a crucial role. Brain function seems probably results from an interaction between genes and experiences. This interchange affects mental health, behaviour, personality, and other neurological functions. As to exactly how genes and environment interact to regulate our neurodevelopmental operating systems, remains a mystery.
Physical diseases such as infections, injuries, and side effects of drugs, can certainly affect the developing brain and may lead to longterm behavioural and emotional problems. What is less certain is how emotional stress, poor parental upbringing, and inappropriate school teaching, can destabilize neuronal connections and lead to mental health problems.
Management
One cannot tell if a child has mental health problems just by looking at them. To the outside world they may look perfectly normal. Feeling sad, feeling angry, or feeling stressed out, are all parts of life, just as it is normal to feel happy, confident and carefree sometimes. Positive and negative emotions come and go, depending on what is happening around that person. How does one tell if a child is having significant emotional problems? And if they do have such problems, how does one go about restoring them back to mental health? Here are some steps that practitioners have recommended for both the child as well as the adult:
1 Talk
This is the most important step to take. Talk to your child and listen to their feelings and thoughts without any pressure or judgement. Sometimes overwhelming feelings are brought on by events in one’s life, sometimes they happen for no reason at all, and it may be helpful to talk about these emotions. For adults, if you have direct voice contact with your friend or colleague, you can use this means to share your thoughts. Alternatively, you can communicate with them via social media.
2 Exercise
One of the best tools for treating anxiety and mild depression is physical exercise. Help your child exercise at home, or play indoor or outdoor sports. If the gym is open, you can go there more regularly. Even if you are in a lockdowns or stay-home notice, you can try to get some fresh air on the balcony. But if it is possible, go outdoors for exercise and walks.
3 Take a Break
Take a break and do something your child enjoys: drink a hot drink, watch Netflix, play with a pet, or whatever makes you and your child feel better.
4 Express Your Feelings and Thoughts
Encourage your child to write a journal or a blog, write some poetry, do some art, or music …
… or do some photography, start a Vlog, or dance on TikTok.
5 Volunteer to Help Others
Volunteer for social service: you and your child can help deliver food and groceries to disadvantaged people, give online tuition for the underprivileged, or learn to be a mental health advocate.
6 Mindfulness
You can practice mindfulness or do some yoga.
7 Consult a Professional
If you or your child is still feeling down, you might consider consulting someone else who might be able to give some professional advice.
8 Limit Access to the Daily News
No news is good news. Currently most of the news on television and newspaper tend to focus on bad news, such as the spread of COVID-19 and the mortality rate. Therefore, it may be advisable to restrict one’s access and time to listen to the news.
Educating Parents, Caregivers and Teachers
The issue of educating caregivers lies at the root of adult emotional literacy. In general, parents are not taught how to be good parents. They are not taught what is the optimal response to their child’s misbehaviours, temper tantrums, and refusals. Asian parents are often viewed as being too strict with their children and they may often resort to caning or physical punishments. They have not been educated on how to display empathy and compassion to a misbehaving child. Many parents discipline their children in the same way that they themselves were disciplined during their own childhood.
How should parents respond to emotional problems or traumatic events? Should they reprimand a crying child and tell them to stop crying, or give them an angry look? Well, this might deter the child from expressing their feelings to their parents, and they will likely repress their emotions. When this scolding recurs over time, the child might react in the form of aggression, rage, or shouting. And then later, this can evolve into bullying behaviour, or even turn up as violence. But if the child is doing something potentially dangerous, then it may be appropriate to shake one’s head and give a stern look.
On the other hand, when parents respond to sadness or crying by saying: “It’s OK for you to express how you are, I will accept all of you, the angry, the sad, as well as the happy bits of you. Let me hold you for a moment.” When you display empathy and compassion to the child, and show that home is a safe place to be, then after they have calmed down, you can explain why you think they should behave in a more rational reasonable way.
However, if the child is crying because you have denied them something they want, then it is important not to capitulate and give them what they want. This would encourage crying as a means to manipulate you, the caregiver to acquiesce to their future demands.
Educating parents, caregivers, and teachers is therefore an important part of child-rearing.
What About The Education System?
The other problem in Singapore and some other countries, is that parents value IQ more than EQ, and some rate exam scores more highly than integrity. Over the years, the educational system has become more rigid, more stressful, more hyper-competitive, and less enjoyable. It is becoming more like an Olympic Games sport that only gives you one chance to prove yourself. It is unforgiving. If you are knocked out in an early round, there is no second chance to allow for a comeback. Many parents send their children for extra tuition in order to gain an advantage in school exams.
Tuition Class
No wonder most Singapore school children are frustrated and stressed out. It makes them perpetually anxious and fatigued, and there is little enjoyment in school life. This can lead to further anxiety, sadness, and depression.
Children develop at different rates and some may be better at certain subjects and not others, or some might excel in the arts or in sports. The rather unimaginative exam system, often using multiple choice questions also limits creative thinking and adds more stress to schoolchildren.
Exam stresses are a perennial problem. Children worry that they are falling behind in their revisions. If they did well in a previous exam, then expectations are for them to do as well, if not better, than their last achievements. And when they do badly, it feels like having won an Olympic medal last time, but unable to defend one’s title currently. Then there is the additional pressure of parental expectations. Parents are hovering in the background and even if they do not voice their demands, their child automatically assumes they desire nothing less than coming top of the class. These pressures can be overwhelming, especially for schoolchildren.
The inability for children to physically attend school during periods of pandemic lockdown, the restrictions of going outdoors and being stuck at home, the change in classroom teaching to home-based Zoom learning, has had some adverse emotional impact.
Suicide rates among school children has been high, but recently with COVID-19, there has been an increased spike in cases (7,8). This requires urgent attention. Fortunately Singapore is addressing this problem (9)
Conclusions
Mental health of children, when managed in a sensitive, exemplary way, can lead to a well-balanced, selfless, ethical, humane adult, someone capable of thinking critically and creatively. This requires careful cultivation of appropriate care of children by parents, caregivers, teachers and friends. We recognize that each child is different, and that education needs to be individualized and customized for the different stages of child development. Much more attention must be devoted to this area of child development. Hopefully changes will come soon.
For information about mental health in Singapore, go to the Institute of Mental Health Singapore’s website (10) . You can also read my article on Depression and Suicide (11).
National Care Hotline: 1800-202-6868 (8am to noon)
Mental Well-Being Mental Health Helpline: 6389-2222 (24 hours) Samaritans of Singapore: 1800-221-4444 (24 hours) Singapore Association for Mental Health: 1800-283-7019 (Mon to Fri 9am to 6pm) Silver Ribbon Singapore: 6386-1928, 6509-0271 (Mon to Fri 9am to 6pm) Tinkle Friend: 1800-274-4788 (Mon to Fri 2:30 to 5pm)
Counselling Touchline 1800-377-2252 (Mon to Fri 9am to 6pm) Care Corner Counselling Centre (Mandarin): 1800-353-5800 (10am to 10pm)
Written by Kenneth Lyen 28 July 2021
Posted in Uncategorized | Comments Off on Mental Health in Children
Children follow a familiar timetable for development, a given calendar for achieving motor, communication and social skills. Like the steps of a staircase, one climbs one step at a time.
Climb one step at a time
Most children learn to walk and talk soon after their first birthday. They join two to four words into a phrase by 2 years, copy a circle by 3 years, and count up to 10 around 4 years old. Parents get very worried when their child does not reach these milestones at the expected time, and they might ask around to check if their child is developmentally delayed. They get even more worried when they hear that their child is suspected to be “intellectual disabled”. What does this term mean?
Definition (1,2)
Intellectual disability is an impairment of mental abilities that impacts adaptive functioning, with an onset during a person’s developmental period (<18 years).
The intellectual function is significantly below average when formally tested, and the IQ score is <70. This results in problems with one’s abilities in learning, reasoning, and problem-solving.
Intellectual function can impact adaptive behaviors, and the areas affected are classified as conceptual, social and practical skills:
Conceptual: Learning a language and literacy skills
Ability to handle the concepts of numbers, money, and time
Capability of self-direction so as to live independently
Social: Interpersonal skills
Social responsibility
Self-esteem
Gullibility, naivete
Social problem solving/rules
Practical Skills: Daily living activities, personal care
Occupational skills
Healthcare
Travel and transportation
Use of money and the handphone
IQ Tests
The definition of intellectual disability is based on the IQ test. There are several IQ tests available for children over the age of 1 year (4). However, it is sometimes difficult to decide which test is the best. For children under 2 years old the Bayley Scales for Infant and Toddler Development (Bayley III) is the only one available. For children above the age of 2 year, the Wechsler Intelligence Test for children (WISC) is popular. The oldest test, the Stanford-Binet IQ test is also available and some psychologists are still using it.
The problem with conducting IQ tests on children is that their cooperation is essential, but this may not be forthcoming. There is an error of plus or minus 5 points using the same test. About 14% of children’s IQ will change by 10 points or more on follow up, over a 2-year period. At the 95% confidence point, several IQ tests report a confidence interval of 25 points, which is rather high. Different IQ tests have shown scores that can vary by 12 points. Hence the inaccuracy and instability of IQ test scores especially when applied to children, makes one wonder about their reliability, and whether a wrong reading can be problematic (5).
Exclusionary Criteria
Factors that can distort IQ testing include the presence of other factors, such as hearing or visual impairment, or if the child has attention deficit hyperactivity disorder (ADHD), or is feeling sleepy, or cannot read clearly because of dyslexia. Therefore, to come to a more accurate diagnosis of intellectual disability one must rule out the following:
Visual, hearing or motor disability
Autism, ADHD, dyslexia
Emotional disturbances
Cultural factors
Environmental or economic disadvantages
Limited English language proficiency
Ensure that the IQ test is conducted by an experienced qualified psychologist who has given appropriate instructions understood by the test subject. If the results are unclear, it may be necessary to repeat the assessment.
Levels of Intellectual Disability (ID)
It is traditional to classify the degree of intellectual impairment based on the IQ score, and one then tries to correlate the score with the degree of support the individual might requires in daily life:
IQ 55-69 Mild Intermittent support
IQ 40-55 Moderate Limited support
IQ 20-40 Severe Extensive support
IQ <20 Profound Pervasive
Using the level of IQ to match their functioning level is problematic, because it is not an accurate reflection of life skills. Rather than use the IQ score as the basis, it is better look at it the other way round, and base one’s assessment on needs, rather than an inaccurate IQ number:
Mild: People have mild ID if they are able to live independently as an adult, and most should achieve primary 6 level of schooling.
Moderate: An ID is considered moderate if they may not be able to live independently and need limited support, and they should be able to reach primary 2 level of schooling.
Severe: Severe ID is now referred to as those who need extensive support.
Profound: Profound ID requires pervasive support.
How Common is Intellectual Disability?
The estimated worldwide prevalence of intellectual disability is between 1-3% of the population (3). How does it compare with other childhood disorders?
Hypertension 1 in 6
Asthma 1 in 12
Diabetes type 2 1 in 12
Epilepsy 1 in 26-100
Intellectual disability 1 in 33-100
Infant mortality ratio 1 in 166 live births
Autism spectrum disorder 1 in 150
Cerebral palsy 1 in 200-300
Childhood cancer (all) 1 in 333
Down Syndrome 1 in 800
Causes
Intellectual disability is thought to be the result of miswiring of the nerves in the central nervous system. This results in slowing down or even stopping nervous signals in their tracks. The brain is our supreme command centre which controls our thoughts, our memories, our speech, the movement of our limbs, and the function of many organs inside our body.
Damage to the developing brain causes miswiring of the nerves, and this can occur before, during, or after birth. We divide the causes into two major categories: genetics and environment. We realise that these two divisions may not be totally isolated from each other, and they can interact with one another. To this day, unfortunately, there are still people with intellectual disabilities where we cannot fathom the cause(s), and they remain a mystery.
Genetic Causes (6)
Genetic causes include chromosomal abnormalities, inborn errors of metabolism and random gene mutations. There are literally hundreds of genetic causes, listed in the given references. The commonest chromosomal abnormality associated with intellectual disability is Down Syndrome. Gene mutations are also found in William Syndrome, Prader-Willi Syndrome, Fragile-X Syndrome, Rett Syndrome, etc.
Rett Syndrome X-Chromosome
What is the link between genetics and brain development?
Genes control protein synthesis and all cells, including nerve cells are made of proteins. The function of cells are controlled by enzymes and other proteins. Hence genetic mutations of brain cells can result in abnormal protein production, hence potentially affecting the structure and function of the brain.
a) Brain malformation affecting the structure of the brain
Microcephaly restricts the development of neurons
Macrocephaly
Abnormalities in brain architecture eg Lissencephaly
Agenesis of the corpus callosum
b) Disruptions in cellular metabolism with anomalies in the manufacturing and regulation of molecules essential to the brain and nerves
Insufficient transport of necessary substances inside the cell
Inadequate protein formation (transcription and translation)
Lack of energetic substrates for the cell (mitochondria)
Accumulation of toxic substances
c) Abnormalities affecting the ability of neurons (the main brain cell population transporting information) to connect to each other: brain plasticity
Brain plasticity is essential to acquire new skills through the many connections between neurons as experienced and stimulated by the environment
When cerebral plasticity is impaired, brain functions are restricted, resulting in altered information processing, inappropriate emotions and language difficulties, making it difficult for the person to adapt to the environment
At the same time the brain becomes more excitable and less able to filter information to protect itself from sensory over-stimulation and strong emotions
In addition to intellectual disability other disorders may accompany the intellectual delay:
Language disorders
Learning delays
Emotional control difficulties
Motor disorders
Epilepsy
Behavioral disorders
Sleep disorders
Eating disorders
Genetic defects may not be limited to neuronal cells: other organs may include heart, kidneys, eyes.
Environmental Causes
Problems during pregnancy can affect the developing foetus, including hypoxia, maternal drugs, alcohol abuse, infections, etc. These can cause brain damage leading to intellectual disability.
Postnatal causes: jaundice, infections (meningitis, whooping cough), drowning, accidents, exposure to drugs and chemicals, malnutrition, can affect brain development.
Investigations
A doctor needs to take a full medical history and do a physical examination including doing a thorough neurological examination, and looking for signs of hypothyroidism. The height, weight, head circumference and blood pressure must be measured.
Laboratory tests should include thyroid function, vitamin D level, full blood count, tests for congenital infections, and chromosome studies.
Magnetic resonance imaging or computed tomographic scan, and skeletal Xrays may be necessary.
Therapy
Currently, there is no cure for intellectual disability, at least not yet. We are able to help these children achieve their maximum potential through special education and several intervention therapies, including speech therapy, occupational therapy, physiotherapy, music and art therapy. Should the individual display other disorders, such as epilepsy, ADHD, depression, sleep disturbances, etc, they should be treated if and when these symptoms arise.
Gene and CRISPR Therapy
CRISPR Gene Therapy
Some gene mutations can lead to the production of abnormal proteins which might cause disruptions of nerve connections. If this were the case, then can we replace the defective or missing gene(s)? The answer is not at this moment. But looking at the successful introduction of gene therapy for other genetic diseases like haemophilia, severe combined immunodeficiency and retinitis pigmentosa, and CRISPR technology for sickle cell anaemia (9), it will not be long before gene therapy might become available for neurodevelopmental conditions.
Dietary Therapy
It has been observed that deficiency of vitamin D, vitamin B12, folic acid, iodine, and severe iron deficiency is associated with impaired intellectual function. Mental activity improves when these deficiencies are corrected. We are already treating metabolic diseases like phenylketonuria and galactosaemia by avoiding phenylalanine and/or milk. Other dietary manipulations that have shown benefits, include a ketogenic diet rich in fat plus non-synthesized vitamins such as biotin or thiamine, or by providing a missing enzyme with enzyme therapy.
Tuberose Sclerosis
Tuberose sclerosis is an autosomal dominant disorder causing intellectual disability and severe epilepsy. The mTOR molecular pathway becomes hyperactive when stimulated by the hamartin protein manufactured by the defective genes. A new drug, everolimus has been approved by the US Food and Drug Administration for use in tuberose sclerosis (7).
Fragile-X Syndrome
Fragile-X Syndrome is inherited as an X-linked dominant. It causes a disruption of the GABA and glutamate molecular pathways, resulting in interrupted neuronal communications which leads to intellectual disability and epilepsy. Sertraline, a selective serotonin reuptake inhibitor, has been shown to be helpful in reducing some of the symptoms of this syndrome (8).
Special Education
Early Intervention
Early Intervention at the Rainbow Centre
Early diagnosis and intervention though special education and behaviour therapy has been shown to maximize the child’s potential. The class size should be kept as small as possible so that the teacher-student ratio is kept low. The training and therapy is best conducted by specially trained teachers and therapists. The curriculum is holistic and inclusive, and the pace of teaching is individualized, depending on the rate at which the child progresses.
The areas covered in the early intervention program include:
a) Cognitive domain: learning language, both verbal and written, handling numbers, mathematics calculations, problem-solving.
b) Social and communication skills: This is conducted through direct interaction with the therapists and the student peers.
c) Arts, music, sports: Students learn how to sing, dance, play a musical instrument, they are taught drawing and painting, and play several sports including swimming.
Art Therapy at the Rainbow Centre
d) Behaviour guidance: if the child’s behaviour is challenging (eg too aggressive or too passive), gentle modification is introduced.
For more details regarding referral to Early Intervention and Special Education in Singapore please see the reference below (10).
Continuing Education
In Singapore, there is a trend for the mildly intellectually disabled children to be integrated into regular mainstream nurseries, kindergartens and primary schools. The more severely disabled are still segregated into separate schools. Most special schools take children up to the age of 18 years. Sheltered workshop and training for outside employment for those above 18 years is still limited.
Helping the Family
When parents are informed by the doctor that their child could be intellectually disabled, they may take the news badly, and either disbelieve the information, or become depressed. It is important for the doctor to be prepared for either response, and if the parents might like to have a relative or friend also to be present when the diagnosis is being presented. It is important for the doctor to spend time to listen to what the parents feel, and if the do not believe the news, then either have someone else also talk to them, or invite them back for another consultation. The parents may want to seek a second opinion, and the doctor should be able to recommend someone else. The doctor might take a neutral or slightly optimistic long-term forecast on how the child can improve with early intervention and treatment. It is best to give the family some hope.
Conclusions
Intellectually challenged children are declining in numbers, thanks to preventive measures like rubella and other vaccinations, and better antenatal and birth management. Gene and CRISPR therapy is starting to show some promise, but they are not readily available for the time being. Medicines can be used to treat some of the associated conditions, such as epilepsy, ADHD and depression. The backbone of therapy for these exceptional children is education supplemented by speech and other therapies. Intervention should be introduced as early as possible to maximise the child’s potential. It is hoped that in future these children can become more fully integrated into the mainstream educational system. We should treat them as part of our family, and take care of them from birth to departure as family members.
“I brought my 6-year-old son to see you because his teacher says he has attention deficit hyperactivity disorder (ADHD)”, an anxious mother told me. “He cannot sit still, keeps on interrupting the teacher by asking endless questions, and does not pay attention, reading books all the time.” I asked mother what her son was particularly interested in, and the boy immediately barged in saying he was interested in the ice tundra, astronomy, dinosaurs, and Harry Potter books. All the while, he was fidgeting in his chair, twirling round and round. His mother told him that despite getting bad reports from the teachers, he always did well in mathematics and other tests.
I referred him for formal psychological testing and the report said that this boy did not have ADHD, but rather he had gifted intelligence. His behaviour was overactive, not hyperactive, probably because he was able to learn things very quickly, and got bored in class when lessons dragged on at a snail’s pace.
Definitions
There are many adjectives we use to describe intelligent people, such as “clever”, “smart”, “bright”, “brainy”, scholarly. Some intelligent people are especially talented in certain areas, like mathematics, language, music, art and sports. Does that mean there are many types of intelligences? And what is the relationship between giftedness and intelligence? And how does giftedness differ from talent? First, let us try to define these concepts.
Intelligence
Intelligence can be defined as a general mental aptitude that involves several capabilities, including the abilities to reason, to solve problems, to think abstractly, plan ahead, learn from experience, understand and memorize complex ideas.
Intelligence can be measured by an IQ test. However, this is limited to mathematics, visuospatial and language measurements, but it appears that there appears to be a general factor (g factor) which crosses into other assessments of intelligence (see below for IQ tests).
Giftedness
Giftedness is a quality or attribute where a person displays exceptionally high achievement capabilities in areas of intellectual, creative, artistic, leadership capacity, or in specific academic fields.
Children may be born with the potential of developing giftedness. In other words, there is a gifted genetic seed which can grow and flourish best when given the right nourishing environment.
Giftedness is usually linked to a high intelligence, with an IQ of 130 or higher, which is found in the top 2% of the general population.
Gifted intelligence IQ >130
Talented
To be talented is to have the natural ability or skill to do something very well. Often the areas of ability are in the arts, sports, and school performance.
Gifted vs Talented
The major differences are that gifted people display outstanding natural abilities and exceptional talents. There are far fewer gifted people in the general population. Talented individuals are also very skillful and have brilliant abilities in many areas including dance, music, design, sports, writing, and arts. Gifted people tend to think differently, and are more driven. However, there is some overlap between gifted and talented persons. Major differences are outline in the table below:
Talented vs Gifted
IQ Tests and the Labeling of Giftedness
Despite the limitations, the most objective tests for diagnosing giftedness is the IQ intelligence test. The Stanford-Binet test was developed by Lewis Terman, the professor of psychology at Stanford University, in 1917. It was modified from the original Binet-Simon test (1905), and remains the foundation of current IQ tests.
Since then, there have been many more IQ tests developed. For children, the most popular is the Wechsler Intelligence Scale for Children.
For entry into many educational programs, the IQ test forms an important component of the entrance exams. For example, entry into the Singapore secondary schools requires students to sit for the Primary School Leaving Exam (PSLE). For university entry, the US universities have a Scholastic Assessment Test (SAT), the British medical schools’ tests include the University Clinical Aptitude Test (UCAT), the BioMedical Admissions Test (BMAT), and for international students applying to Australian medical schools, they have to take the International Student Admissions Test (ISAT). A major component of all these exams is the IQ test.
Gifted Education
Gifted education class
It has long been recognised that some gifted children have difficulties negotiating the conventional educational system. Their minds are racing ahead, but they are dragged back by their slower classmates. Therefore, many countries offer education for gifted children on a voluntary basis.
In order to be admitted into such a program, children have to take a special exam, which includes an IQ test.
In Singapore, the top 1% of that year’s cohort are admitted to the gifted program. IQ forms the major component of the selection criteria. Although the actual IQ might fluctuate from year to year, in general the gifted program selects children whose IQ are greater than around 140. The test is taken when the child is 9-10 years old.
There has been a lot of debate concerning gifted education. The first is the use of IQ tests for admission into the program. Below are listed the pros and cons of using IQ tests to select students:
Pros and Cons of IQ Test Scores
Interviewing children and parents who have been through gifted educational programs, the general consensus is that the benefits of the gifted education system outweigh the risks of remaining in a regular mixed ability class. Most children enjoy the program, they like to mix with children of similar intellect, they love being taught by better teachers, being stretched academically, and covering the curriculum at a greater depth. The majority of these gifted children continue to do well right through university and their chosen future professions.
One of the recurring objections to the gifted education program is that it creates a class of elites. One teenager in the gifted education program was asked if she knew a child attending a normal class in her school, and she answered: “I do not mix with normal students”! To minimise this concern of superiority and elitism, many gifted education programs try their best to integrate the children of all abilities to participate together in non-academic areas including art, music, drama, sports, and community service.
Some critics say that not all gifted children remain gifted throughout their lives. This criticism has been tackled by allowing free flow of gifted children in and out of the program. Singapore only accepts children in the top 1% of the population into the gifted program, and both the child and the parents must accept the opportunity being offered; thus reducing the possibility of making wrong admission choices.
If a child is gifted in a narrow area, such as language, mathematics or science, there may some pressure by the parents to try to accelerate the learning in these areas. Promoting the child to an older class can potentially create some problems. Children develop different skills at different rates, and this is referred to as asynchronous development. For example, an 8-year-old child may have the language ability of a 14-year-old, and if they join a class of older children, their social and emotional development may be out of synchrony with the older children. One solution of this dilemma is to have special individual tuition devoted to the academic areas appropriate for that child.
A flexible individualised educational system is recommended. With technological advances in education, perhaps this pipe dream may be realised in the near future.
Multiple Intelligences
Another criticism of using conventional IQ tests for selecting students for the gifted education program is that it assesses a relatively narrow range of abilities, namely mathematics, language, and visuospatial. Howard Gardner originally suggested 7 intelligences in 1983, but he has increased this number to 9. They include:
Visual-spatial
Linguistic-verbal
Logical-mathematical
Bodily-kinesthetic
Musical
Interpersonal
Intrapersonal
Naturalistic
Existential
Howard Gardner’s Multiple Intelligences
If we look at education more holistically, then gifted children who excel in only a few areas, should nevertheless be given the opportunity to explore other areas.
Problems of Gifted Children
Parents seek medical or psychological consultation for their gifted child because they might develop some challenges related or arising from their giftedness. These problems can arise not only in gifted students attending non-gifted classes, but also in those going to gifted classes. The problems include:
a) Attention Deficit Hyperactivity Disorder (ADHD)
The 6-year-old boy described in the opening paragraph, is one such example. The psychologist did a formal assessment, and found that he did not have ADHD, but instead he was gifted. The explanation of the restless behaviour, failure to pay attention, and his constantly interrupting the teacher, is attributed to his amazingly fast ability to learn. The teacher caters to the average student, and spends longer repeating the lesson, which bores the gifted student.
b) Disruptive Behaviourand Poor Social Skills
Some gifted children get so fed up with the slow pace of the teaching that they engage in other activities, like chatting with their neighbours. Others are perfectionists and keep on correcting their teachers or classmates when they say something deemed incorrect. Some gifted children have poor social skills and do not know how to interact with their peers. They may be perceived by their peers to be egoistical or arrogant, and this can lead to arguments, fights, and ostracization.
c) Depression
Depression and suicides are found in gifted children, but it is controversial whether or not it is more frequent in gifted children compared to their age-matched non-gifted peers. It has been suggested that gifted children are more prone to depression and suicide because they have heightened sensitivities, they tend to be introverted, overachieving perfectionists, or they become extremely worried if they do not fulfil their self-imposed high standards, and they may be prone to bullying by their non-gifted peers.
d) Twice-Exceptional
The term twice-exceptional refers to a person who is both gifted as well as being disabled. For example, it may be a person who has a very high IQ and is also autistic. The special needs may be a learning disability, dyslexia, attention deficit hyperactivity disorder, visual or hearing impairment, or motor deficits. If their accompanying disability is missed or ignored, these talented children may be under a lot of pressure, may lose motivation and therefore under-achieve.
Terman’s Termites
Lewis Terman (1877-1956) was the founder of the Stanford-Binet IQ test, which was introduced in 1916. In 1921 he began a longitudinal genetic study of highly gifted children, which were later dubbed as “Terman’s Termites”. They were followed up until they reached 70 to 80 years of age. Altogether he recruited 1,528 participants between the ages of 3 to 28, who had an IQ of >135, comprising 1% of the general population, which he defined as “genius”. There were 856 boys and 672 girls, mostly from California, and they were predominantly white and middle class. The finding was summarised as: “the gifted child becomes the gifted adult”. His Termites had ten times the national rate of earning a university bachelor’s degree of that era. A significant number of graduates went on to earn postgraduate degress: 57 doctors, 92 lawyers, and 97 PhD’s which was a high percentage of that time period. The salaries of his Termites was also significantly higher than the matched median per capita income.
It is of interest to note that two subjects rejected by Terman because their IQ fell below 135, went on to win a Nobel Prize each. Hence the joke suggesting that if you want to win a Nobel Prize, you should not have too high an IQ!
Lewis Terman recommended helping highly gifted children with special gifted education, trained teachers, employing enriched and accelerated curriculum. The benefits of this approach has been vindicated by more recent studies in several other countries.
Contemporary Gifted Persons
William James Sidis enrolled in Harvard University at the age of 9 years. He predicted the existence of regions of space where the second law of thermodynamics operated in reverse to the temporal direction.
Christopher Michael Hirata won the International Physics Olympiad at the age of 13 and graduated from Caltech at the age of 18. He is a leading exponent of precision cosmology, combining interdisciplinary computer studies, theoretical studies, and observational astronomy. His achievements are in the field of dark energy and the accelerating expansion of the universe.
Christopher Langan obtained a perfect SAT score but dropped out of university because he could teach his professors more than they could teach him. Langan has developed an idea he calls the “Cognitive-Theoretic Model of the Universe” which he maintains “explains the connection between mind and reality”.
Terence Tao is an Australian-American whose Hong Kong parents emigrated to Australia. He attended a university mathematics course at the age of 8 years, and co-authored over 300 research papers, including formulating the Green-Tao theorem for which he was awarded the Field Medal, which is considered the mathematics equivalent of the Nobel Prize. He is also referred to as the “Mozart of Maths”.
Kim Ung-Yong got his PhD degree at the age of 8 years. At the age of 15, he was doing research work for the National Aeronautics and Space Administration (NASA). He is currently the Vice President of North Kyeong-gi Development Research Center.
Philip Emeagwali is a Nigerian computer scientist whose simulation was the first program to apply a pseudo-time approach to reservoir modeling. At the age of 35 he received the Gordon Bell Prize for an application of the CM-2 massively-parallel computer.
Marilyn Vos Savant is an American magazine columnist, author, lecturer, and playwright.
Edith Stern graduated from university at the age of 15 and is an American inventor and mathematician. She holds over 100 USA patents, and was the former Vice-President for Research and Development at IBM.
Ainan Cawley is a Singaporean living in Malaysia. At the age of 8 years, he was attending a chemistry course at the Singapore Polytechnic, and at 9 years of age, he could memorize π (pi) to the first 518 decimal places. At the age of 12 he wrote the script and composed the music for a short film.
Conclusions
Gifted children are valuable human resources for any country. If nurtured appropriately and allowed to reach their maximum potential, they can contribute to the future of their country and the world.
Neihart M, Teo CT. Addressing the needs of the gifted in Singapore. file:///D:/Medicine/Gifted/Gifted%20Education/Singapore%20Gifted%20Education%201.pdf
Neihart M, Tan LS. Gifted education in Singapore. file:///D:/Medicine/Gifted/Gifted%20Education/Singapore%20Gifted%20Education%202.pdf
Today I learnt that one of my student’s close friend had committed suicide. And only a few months ago, one of my colleague’s son had also committed suicide. It is devastating for these families when their young ones, in their early 20s, end their lives.
The Straits Time of the 8 July reported that there were 452 suicides in Singapore in 2020 (1), and the Malay Mail of 29 June stated that in the first quarter of 2021 there were 631 suicides in Malaysia, far higher than in previous years (2). Why do people take their own lives? Is the increase in suicide rates related to the Covid-19 pandemic? I will discuss this later. But first I will examine depression.
What is Depression? (3,4)
It is a feeling of sadness that is felt more intensely and lasts longer than the transient heartaches, disappointments and blues that we all encounter in our daily lives.
Clinical Presentation
There’s a difference between “having depression” and “feeling sad”. We all feel very despondent when we fail an exam, get rejected by an institution of tertiary education, or lose our job. We feel sad, but after a while, we pull ourselves together and overcome this temporary unhappiness. In contrast, clinical depression lingers on for much longer, sometimes two weeks or more. It interferes significantly with our studying, working, playing, eating and sleeping.
Symptoms of depression
The following symptoms are listed in the American Psychiatric Association’s Diagnostic and Statistical Manual 5th Edition (DSM-V) (5):
Low mood, feeling sad most of the day, occurring nearly every day
Loss of interest in things one normally enjoy
Changes in appetite leading to significant weight loss or gain
Feeling restless, agitated, pacing up and down, psychomotor impairment like slowing of thoughts and movements
Extreme fatigue, loss of energy
Feeling of worthlessness or excessive guilt
Poor concentration, lowered ability to think or pay attention
Inability to sleep, or oversleeping
Recurrent thoughts of suicide or have attempted suicide
Diagnosis
According to the DSM-V, you need five or more of the above symptoms to qualify for a diagnosis of depression, On top of that, there are the following additional requirements: these symptoms must cause significant distress to one’s daily life. They cannot be due to the consumption of medicines known to be associated with depression. One needs to exclude substance abuse, and other medical or mental conditions, such as a schizoaffective disorder. There cannot be a manic or hypomanic episode at any point.
Depression can affect men and women all the way from early childhood to old age. No socioeconomic status or ethnic groups are exempt from depression.
Other Symptoms Associated with Depression
We have listed above the official DSM-V symptoms of depression, but most people who have been working with individuals who suffer from this condition are aware of other symptoms listed below, and they should be looked out for:
Irritability and anger
Memory loss
Self-blame
Brooding and rumination
Social withdrawal
Blunted circadian rhythm where the timing of the sleep-wake cycle is disturbed
How Depression Affects One’s Daily Life
There are many ways in which depression can affect one’s daily life. These include:
Hampering academic studies or work performance
Disrupting meaningful relationships with others
Slowing down in getting things done
Eating a poor diet and becoming malnourished
Depression in Children
Depression in children is quite difficult to pick up, and the diagnosis is often delayed or missed. Symptoms may not be constant, and can fluctuate from day to day, depending on the environment and events. As a child grows up, the manifestations of depression can unfold differently at different ages. One must have a high index of suspicion if a child has continuous feelings of sadness or hopelessness, if there are bouts of anger or crankiness, if they become socially withdrawn, display changes in appetite or food preferences, change their sleep patterns, have difficulty concentrating on schoolwork, cry a lot, or have thoughts of suicide. Some may even present with superficially unrelated symptoms like headaches and abdominal pain, so caregivers and doctors should be alert to the possibility of an underlying depression.
Cyberbullying
Subtypes of Depression
a) Peripartum Depression
Post-partum depression or “Baby Blues” usually occurs after childbirth, but studies have shown that some mothers may have depression prior to childbirth. Thus, the condition has been renamed “depressive disorder with peripartum onset”. It can occur during pregnancy or up to 4 weeks after birth. Some 10-15% of mothers experience postpartum depression. Symptoms include mood swings, frequent crying, trouble bonding with the baby, tiredness, a fear that they will not be a good mother, or a sense of worthlessness or shame. In women, several hormones including estrogen, progesterone, prolactin and cortisol all decrease significantly after childbirth, and this drop may be responsible for causing the depression. Lifestyle changes may also play a role, because men can also experience depression around the same time. In men, their levels of testosterone and vasopressin fluctuate during and immediately after their female partner’s pregnancy, but the precise mechanism of depression in males is still unclear. Both males and females will experience environmental changes such as dealing with an unconsolable baby, sleep deprivation, changes in one’s daily routines, and having difficulty finding adequate support to take care of baby.
b) Atypical Depression
Atypical depression is characterised by increased sensitivity and reactions to changes in the environment. There may be improved mood during positive events, and this is referred to as “mood reactivity”. This contrasts with “melancholic depression” where even previously pleasurable events do not elevate one’s moods. Atypical depression may exhibit increased appetite, weight gain, heavy feeling in the limbs (leaden paralysis), oversleeping, and and becoming extremely anxious when being scolded or rejected.
c) Persistent Depressive Disorder (Dysthymia)
This subtype is a chronic form of depression which lasts over longer periods of time usually more than 2 years. The severity can also fluctuate over time. Symptoms include changes in appetite, changes in sleep, fatigue or low energy, reduced self-esteem, reduced concentration, struggling to make decisions, feeling hopeless, and harbouring pessimistic thoughts.
Differential Diagnosis
Bipolar Disorder (6)
Bipolar disorder was formerly known as manic-depression, and is characterised by extreme mood swings between hyperexcitable behaviour followed by depression. Some patients are misdiagnosed as suffering from depression. One should try to find out if the person has up and down mood swings, and if there are manic episodes, then this points towards a diagnosis of bipolar disorder. The reason why it is important to make a correct diagnosis is that the treatment differs from depression. Lithium carbonate is the preferred treatment for bipolar disorder.
Seasonal Affective Disorder (SAD)
Depression that occurs either in the winter months or during spring-summer months are diagnosed as Seasonal Affective Disorder (SAD). In those countries where the winter months are cold and the sun sets early resulting in dark afternoons and evenings, can make some people feel rather moody and, as the acronym suggests, sad. It has recently been realised that there is also depression that can occur during the spring and summer months. It is thought that this form of depression is due to allergy to pollen.
Causes (7,8)
The causes of depression are still not fully worked out. There have been a lot of research being conducted utilising advanced technology, and the results are still coming in.
Genetics (9)
If a first degree relative has depression, then one has a higher risk of getting depression too. If an identical twin has depression, the other twin has a 60-80% chance of developing it. A non-identical twin, on the other hand only has a 20% chance of experiencing depression.
The vast majority of individuals suffering from depression do not have close relatives with this condition. Because depression is a heterogeneous condition often overlapping with other personality, behavioural and psychiatric disorders, and there are no laboratory or imaging techniques to make a definitive diagnosis, there is a problem. Is depression a single disease, or is it made up of several diseases with some common and some overlapping symptoms? Therefore, what exactly can one correlate any particular set of candidate genes with?
Unlike other major psychiatric disorders like autism, genetic studies have not achieved very promising results. Following the successful human genome project, where the entire human DNA was mapped out in 2003, several Genome Wide Associations Study (GWAS) have been conducted in many countries, using large sets of samples, including thousands of patients with different forms of depression, and meta-analyses of thousands of patients scrutinised. Unfortunately, all have failed to identify any specific gene loci responsible for the predisposition to depression.
Recently there have been some suggestions that perhaps mitochondrial dysfunction may play a role in the development of major depressive disorders. If true, this throws a spanner in the works!
Environmental Factors
Life Events
Failing an exam
Tragic events, like the death of a family member, failing an exam, losing a job, getting divorced, can increase the chances of having depression. A traumatic childhood, sexual or psychological abuse, neglect, poverty, and unhealthy lifestyles, can also predispose one to develop depression later in life. The side effects of certain medicines, like corticosteroids, beta-blockers, and statins (treatment of high cholesterol levels), can result in depression. Recreational drugs, like amphetamines, can also lead to depression.
Based on a combination of genetic and environmental factors, it is postulated that depression has neurochemical and neurostructural aetiologies.
Neuropathology of Depression (10)
The commonest theory about the cause of depression is the theory of chemical imbalance in the brain, especially the lack of serotonin, the “feel good chemical”. This is based on the observation that raising the level of serotonin through medicines can alleviate symptoms of depression in some patients. However, this view does not really capture the complexity of depression.
a) Monoamine deficiency theory
The underlying basis of depression is low levels of serotonin, noradrenaline or dopamine, the monoamines. Each may have an impact on separate sets of symptoms:
Serotonin: obsessions and compulsions
Noradrenaline: anxiety and attention
Dopamine: attention, motivation and pleasure
If one of these monoamine neurotransmitters is down, it may lead to a specific set of symptoms felt by the patient.
Serotonin is thought to be a major player, and perhaps even regulating the other neurotransmitter systems.
Tryptophan depletion: this is the amino acid which the body uses to make proteins including serotonin. Its depletion can lead to symptoms of depression. It also links to DNA studies of depression.
b) Neural Growth and Connections Theory
In recent years, scientists have discovered that brain cell growth and connections may play a larger role in the cause of depression. The hippocampus tends to be much smaller in depressed patients. The hippocampus is the area of the brain that controls memories and emotions. The longer the person has been depressed, the smaller the hippocampus becomes. Stress may be the main trigger to decrease the number of new neurons in this area of the brain. When this area of the brain regenerates and new neurons are stimulated, the mood improves. Many drugs include those that affect serotonin levels, have an indirect effect on the growth of brain cells. Cells that secrete serotonin also secrete other chemicals that stimulate growth of new neurons or neurogenesis.
Investigations
Magnetic Resonance Imaging (MRI)
Magnetic Resonance Imaging shows structural changes in the brain, and this has shown that a part of the prefrontal cortex known as the ventromedial cortex is much smaller in depressed individuals. The ventromedial cortex enables an individual to be stimulated by positive rewards and experience pleasure. It also enables one to switch from one mood to another mood. The cells involved in this function are the glial cells which supplied nerve cells with energy, and the number of these cells is decreased.
Positron Emission Tomography (PET) Scan
Function Magnetic Resonance Imaging (fMRI)
PET scan showing reduced activity in the prefrontal cortex and other areas of a depressed individual’s brain
Positron Emission Tomography (PET) Scan allows scientists to determine the metabolic rates of the brain by measuring oxygen and blood sugar (glucose) utilization. Findings from PET scans have been confirmed by Functional MRI (fMRI). The latter looks at the blood flow into different areas of the brain. Using both these techniques, scientists have discovered that depressed people have less activity in the prefrontal cortex, including the ventromedial cortex. Paradoxically, there is more blood flow to the limbic area which contains the hippocampus, despite the shrinkage of the hippocampus in depression.
Electroencephalogram (EEG)
There can be changes in the rapid eye movement (REM) pattern as well as the slow wave phase of the sleep cycle. The EEG shows decreased REM sleep latency, decreased slow wave activity, and deeper delta waves in depressed subjects.
Blood Tests
Blood is taken to exclude hypothyroidism, high cortisol levels, vitamin deficiencies, and if consumption of recreational drugs (e.g. amphetamines) is suspected, blood can be taken to confirm their presence. Patients with high cholesterol levels might be taking statins, a potential cause of depression.
Treatments
Between 70-80% will improve their depressive symptoms if treated correctly. Whether or not antidepressants will lower suicide risk is a controversial topic; epidemiological studies have shown conflicting results, some showing increased and others showing decreased risk of suicide (28).
This medicine blocks the reuptake of serotonin in the brain’s synaptic gap, and thereby prolongs the amount of serotonin in the synapse, enhancing neurotransmission. Serotonin is associated with happiness. SSRIs are generally preferred over other medicines, especially in children, adolescents, and late-onset depression. Adverse reactions are also less than other antidepressants. They include gastrointestinal upsets, sexual dysfunction, fatigue and restlessness. Citalopram when given in higher doses may cause prolongation of the cardiac QT interval.
In the 1990s, some 3% of American were taking Prozac, an SSRI antidepressant. The prevalence of consuming antidepressants has quadrupled over the following few decades, and there used to be a joke pointing to the United States as a “Prozac Nation”!
b) Serotonin/Noradrenaline Reupdate Inhibitors (SNRIs) (Veniafaxine, Desvenlafaxine, Duloxetine) (12)
For patients who suffer from pain or extreme tiredness, the SRNIs can be considered as a first-line treatment. SRNIs should be used alone because there are some interactions when combined with other antidepressants. Side effects include dizziness, dry mouth, diarrhoea or constipation.
c) Monoamine Oxidase Inhibitors (MAOIs) (Isocarboxacid, Phenelzine, Selegiline) (13)
Monoamine Oxidase Inhibitors prevent the metabolism of the monoamines 5-hydroxytryptamine (5HT) and noradrenaline, which increases the level of these neurotransmitter monoamines. An important side effect is that the risk of a hypertensive crisis. A low tyramine diet is recommended. Other side effects are insomnia, lack of sleep, anxiety, sexual dysfunction and weight gain.
Tricyclic antidepressants block the reuptake of serotonin and noradrenaline in the presynaptic nerves. They were introduced in the 1950s and are currently used as a second line treatment when other antidepressants are ineffective. They elevate one’s mood. Unfortunately side effects are more common with TCIs, and include drowsiness, blurred vision, dry mouth, constipation, urine retention. They have also been used for people with obsessive-compulsive disorder and can help some who suffer panic disorders.
The NMDA receptor is activated by glutamate and when that happens, a nerve signal is activated. The NMDA receptor antagonist will block the receptor and hence inhibits electrical impulses to pass. The antidepressant effects of the NMDA Receptor Antagonist can be felt relatively quickly, in about 4 hours.
ElectroConvulsive Therapy (ECT) (16)
A small and controlled amount of electric current is passed through the brain while the patient is under general anaesthesia. This induces a brief seizure. It has been around for decades and is used for major depressive patients. It is effective for about 50% of patients,
Deep Brain Stimulation (17)
Quite recently, neurosurgeons have reported successful treatment of several patients’ severe and treatment-resistant depression by implanting a wire with pacemaker-like device right into particular areas of the brain known as the subgenual cingulate region (also known as Brodmann’s area 25), and a part of the middle frontal cortex. The instrument delivers continual electrical stimulation to these brain areas, and this stimulation had a pronounced anti-depressant effect. Exactly why and how this treatment appears to work is unclear. Stimulation of these regions, which connects the limbic (emotion) centres in the brain with the frontal cortex can better manage and regulate one’s emotions. The frontal cortex might then help reduce depressive thoughts. Further research is in the pipeline.
Transcranial Magnetic Stimulation (18)
This is a noninvasive procedure using magnetic fields applied externally to stimulate part of the brain in order to alleviate depression. An electromagnetic coil delivers the magnetic waves to the frontal cortex. It is painless, safe and well-tolerated. The exact mechanism is unknown but it is speculated that the magnetic waves might stimulate that part of the brain which is underactive in people who have depression. Side effects are uncommon, and include headaches, twitching of the facial muscles, lightheadedness, and some tingling sensations. It works in about 30% of depressives, and fails in 50-60% of patients.
Non-Pharmacological Treatments
Psychotherapy (19)
Psychotherapy, or talk therapy, can help alleviate depression, and appears to be better in maintaining longterm alleviation. This includes cognitive behavioural therapy, interpersonal therapy, and psychodynamic therapy. They help the individual to focus on the present, and encourages the regaining of control over mood and function. Success for this type of therapy depends on the relationship between the patient and therapist.
Social Support
Love and support from family and friends helps tremendously. Strong social support leads to better longterm outcomes.
Music and Art Therapy (20,21)
Music and art therapy have both been shown to help people with depression. They make one feel more relaxed, they soothe the mind, and they lift one’s spirits.
Physical Activities (22)
Physical activities
Physical activities help reduce depression. Theories of why it works include the increased release of neurotransmitters, endorphins and endocannabinoids. Also tense muscles are relaxed. Exercising for 20 minutes x3 per week is effective.
Diet (23)
Although the evidence linking diet and relieving depression is not absolutely definitive, it is possible that eating more fruits and vegetables may have some benefits.
Suicide (24,25)
In Singapore, suicide is the leading cause of death for those aged 10-29. In 2020 there were 452 lives lost to suicide, amounting to 5 times more deaths from suicide than transport accidents (1). Males accounted for more than 70% of all suicides in 2020. For every suicide, at least 6 attempted suicide survivors are left behind.
The Risk Factors
Keep a lookout for risk factors. If you hear or observe any of the following, talk to the individual, asking how things are,
Previous attempt or family history of suicide
Depression and other mental health problems
Serious or chronic health conditions, terminal illness
Distressing life events (failing exams, divorce, job loss, death of close ones, etc.)
If you hear someone say anything like the following, take what they say seriously. Do not dismiss it summarily, and do not say “Everything will be all right”. Better to ask “Is there something bothering you?” “Are you unhappy about something?”
“My family will be better off without me”
“My life is meaningless anyway”
“If you don’t love me, I’ll kill myself”
Unusual Actions or Writings
If you see someone doing the following or posting messages on the internet, it is better to err on the side of caution and discuss the matter with that person. “Anything the matter?” “Can we talk about what’s happening?”
Writing about departing from this world, talking about sadness, suicide notes (posting on social media, blogs, group chats, YouTube, etc)
Giving away treasured possessions and saying goodbye
From January 2020, the COVID-19 infection spread rapidly and engulfed the entire world. It changed all our lives. Millions of people have caught the disease, and already over 4 million people have died. Jobs are lost, affecting one’s income, schools and restaurants are restricted, theatre and music performances curtailed, reduced social mobility and social isolation, virtually no air travel, have all made people feel very lonely, and heightened stress, anxiety, frustrations, and hostility. It is estimated that a third of the population are anxious and depressed. Suicide rates have increased markedly (1,2).
At times like this, family, friends and social organisations need to support one another. Mental health counselling services need to be increased. Governments can help by ensuring COVID-19 is under public health control, encouraging vaccinations, and economically they can supplement lost incomes, reduce rental charges, opening up new jobs and training schemes.
Conclusions
It is important to note that suicide is preventable. Just talking to the depressed person can help alleviate suicidal thoughts and prevent a tragedy. Be neutral and do not be judgemental. Telling the person not to worry or that everything will sort itself out, is probably not going to help. Better to spend time listening to the person’s problems, worries, failures, suffering, and fears. Some individuals want to end their life because they want to terminate an unbearably painful situation, but if they can be shown an alternative solution, they may not embark on such an irreversible act. Sometimes you may have to talk to that person’s relatives or mutual friends to make them aware of the situation. If you feel you are not the right person to help, look for someone else who is more likely to be effective. Try to persuade the depressed person or their relatives to seek psychological or medical or any other appropriate help.
24-Hour Helpline: Samaritans of Singapore 1800 221 4444
10. Mayberg HS et al. Reciprocal Limbic-Cortical Function and Negative Mood: Converging PET Findings in Depression and Normal Sadnesshttps://ajp.psychiatryonline.org/doi/full/10.1176/ajp.156.5.675
National Care Hotline: 1800-202-6868 (8am to noon)
Mental Well-Being Mental Health Helpline: 6389-2222 (24 hours) Samaritans of Singapore: 1800-221-4444 (24 hours) Singapore Association for Mental Health: 1800-283-7019 (Mon to Fri 9am to 6pm) Silver Ribbon Singapore: 6386-1928, 6509-0271 (Mon to Fri 9am to 6pm) Tinkle Friend: 1800-274-4788 (Mon to Fri 2:30 to 5pm)
Counselling Touchline 1800-377-2252 (Mon to Fri 9am to 6pm) Care Corner Counselling Centre (Mandarin): 1800-353-5800 (10am to 10pm)
Written by Kenneth Lyen 13 July 2021
Posted in Uncategorized | Comments Off on Depression and Suicide
The commonest cause of dementia is Alzheimer Disease (AD), accounting for more than half the cases. It was first described by Alois Alzheimer when his patient, Auguste Deter saw him in a mental institution when she was 50 years old. She had lost her memory, screamed in the middle of the night, and was paranoid about her neighbours. She died at the age of 55, and autopsy of her brain showed senile plaques and neurofibrillary tangles.
Symptoms
Alzheimer Disease does not come on suddenly or wipe out your memory in a short period of time. Instead, it is like a thief in the night that creeps up on you and over the course of years, slowly robs you of your powers of recall bit by bit. Quite often you are unaware that your mind is going downhill, until one day you meet an old friend and cannot remember their name.
Initially you might forget where you left your handphone, whether or not you switched off the air-conditioner, or what was the message you were supposed to deliver? Later you might forget what day it is, whereabouts you are, the names of your family members and even common everyday objects. Have you ever uttered the phrase: “It’s on the tip of my tongue”? You might keep on repeating the same questions over and over again. You might have mood swings, lose interest in things that used to captivate you, have difficulty sleeping, become irritated easily, get depressed, and withdraw from social interactions. (See Dementia article for more details).
Usually when symptoms become more severe, you or your relatives might decide to have you see a doctor.
Examination
The doctor will do a full and thorough physical examination. They will need to exclude diseases associated with dementia, such as hypothyroidism, hypertension, hypercholesterolaemia, diabetes, depression, alcoholism, Parkinson Disease, Huntington’s chorea, and cancer.
However, there are no specific abnormal physical signs in Alzheimer Disease. Of paramount importance the doctor has to do a careful cognitive assessment to test one’s memory (see Dementia article for more details).
Causes (3)
The pathological findings of Alzheimer Disease are amyloid plaques, neurofibrillary tangles, and cerebral atrophy. However, the causes of Alzheimer are still shrouded in mystery, but there are some interesting recent advances.
Amyloid Plaques
Amyloid Plaques
Amyloid plaques come from amyloid precursor protein (APP), a protein found in nerve membranes. Part of this protein sticks outwards through the nerve membrane, and the other part pokes inside the membrane. At a certain time, it is chopped off by a family of enzymes named secretases. Unfortunately one of the secretase members, called β-secretase, cuts the external part of the amyloid precursor protein in the wrong place, resulting in an insoluble fragment which will aggregate to form insoluble amyloid plaques.
Depending on where the plaques are located, they can cause different types of damage. If it is between synapses, it interferes with nerve transmission from one nerve cell to another. Amyloid plaques have the ability to activate microglia and astrocytes to release cytokines, hence inflaming the immune system to cause damage to the surrounding neurons. The plaques can also be found around blood vessels in the brain, where they can weaken the wall and predispose to haemorrhage.
Tau Proteins and Neurofibrillary Tangles
Neurofibrillary Tangles
Inside nerve cells are microtubule cytoskeletons that hold up the neurons and prevent them from collapsing. These microtubules help shift nutrients and molecules along the neuron. Tau is a protein that holds the microtubules together and preserves their integrity. Somehow the external amyloid plaques send a signal into the neurons and activates kinase enzymes which phosphorylates the tau protein. These phosphorylated tau proteins leave the microtubules, and clump up with other tau proteins to form tangles, known as neurofibrillary tangles, which are located inside the nerve cells. As the neurotubules are no longer supported, they will collapse and the nervous impulses will not signal efficiently, and some of the nerve cells will die prematurely.
Genes (4-6)
When one person has Alzheimer Disease, a first degree relative such as a parent or a sibling, is more likely to be affected. There appears to be two major types of genetic risk factors: a) Monogenic, and b) Polygenic.
a) Monogenic
Monogenic Alzheimer Disease presents at a younger age-group, under 60 years old, and is less common, affecting less than 5% of all cases. Although they may be caused by hundreds of rare mutations, there are three major genes identified: the gene for the amyloid precursor protein (APP) located on chromosome 21, the presenilin 1 (PSEN1) gene located on chromosome 14, and the presenilin 2 (PSEN2) gene located on chromosome 1. How exactly they cause Alzheimer is still being investigated. Some of you may have noticed that chromosomes 21 and sometimes 14 are associated with Down Syndrome who can develop signs of dementia.
b) Polygenic
Polygenic Alzheimer cases present at an older age, greater than 60 years old, accounting for 95% of cases, most of which are sporadic. There is a complex polygenic factor, and there are nongenetic environmental factors. Although there is no one specific gene causing late-onset Alzheimer Disease, researchers have discovered a genetic variant of the apolipoprotein E (APOE) gene on chromosome 19. This discovery sparked a lot of interest because the APOE gene is also associated with the protein that carries cholesterol and other fats in the blood. Scientists are wondering whether there is a connection between Alzheimer Disease and vascular dementia, because they often co-exist in patients; and they ask what is the role played by the APOE gene?
Researchers have not found a specific gene that directly causes late-onset Alzheimer Disease. However, having a genetic variant of the APOE gene increases a person’s risk of developing Alzheimer’s. For example, a subtype of the APOE gene is the APOE e4 allele, and if you have two copies of this allele, it raises the risk of developing Alzheimer’s by up to 25%.
The human genome project was completed in 2003, and was a landmark in opening up the floodgates of genetic research. There is now a Global-Wide Association Study (GWAS) for Alzheimer Disease. Currently 600,000 individuals have been recruited, and a large number of gene variants have been discovered (7). When the results are analysed it will help in the early diagnosis of Alzheimer and can give us clues as to how to prevent or alter the progression of the disease.
Investigations
Blood Tests
Blood tests are taken to exclude suspected hypothyroidism, hypercholesterolaemia, liver and renal function, vitamin deficiencies, HIV-AIDS, and syphilis.
EEG (8,9)
Electroencephalography (EEG) shows abnormalities especially in severe Alzheimer Disease. When EEG is used on its own, it is not diagnostic of Alzheimer’s. When used in combination with other investigation methods, it enhances the diagnosis. EEG is helpful in distinguishing Lewy Body Dementia from Alzheimer Disease.
PET Scans
Positron Emission Tomographic scans are useful for the diagnosis of Alzheimer Disease not only when it is severe, but also in the early stages, known as Mild Cognitive Impairment (MCI). PET scans can also diagnose Lewy Body Dementia, Parkinson Disease and Fronto-Temporal Dementia.
There are two types of PET scans: a) Amyloid PET scans, and b) Tau PET scans.
a) Amyloid PET Scans (10)
Positron emission tomography scans use radioisotope compounds that bind to amyloid. They can be metabolised by the brain tissue surrounding the amyloid, which metabolise both the glucose and oxygen molecules which form part of these counpounds. And when that happens, it releases small amounts of positrons, which will then bump into some electrons. This encounter will generate two γ-rays which will fly off at 180° from each other. A series of γ-ray detectors placed correctly will detect the γ-rays.
Currently the most widely used radioisotope compounds are the fluoride radioisotope compound, 18Fluoro-Deoxy-Glucose (FDG), and 11C 2-(4′methylaminophenyl)-6-hydroxy-benzothiazole. The latter was made in Pittsburgh, and hence it was named Pittsburgh Compound B (PIB). Both are able to detect amyloid plaques in vivo and can therefore diagnose Alzheimer Disease (AD). But recent studies show that the PIB-PET scans are better able to distinguish the different degrees of severity in the milder forms of memory loss, known as Mild Cognitive Impairment (MCI) (see diagram below: naMCI = nonamnestic MCI, aMCI = amnestic or forgetful MCI).
FDG vs PIB PET Scans: naMCI (nonamnesic MCI) aMCI (amnesic Mild Cognitive Impairment)
The PIB PET scans appear to be more useful for mild MCI dementia, as well as diagnosing the more severe Alzheimer Disease.
b) Tau PET Scans (11-13)
Tau PET Scan
The tau PET scan uses the tracer lortaucipir/AV-1451 to detect the tau protein in the brain. In Alzheimer disease there is increased tau proteins. It appears that tau PET scans when used early, may be slightly better correlated with future brain atrophy compared to amyloid PET scans.
MRI Scans
MRI Scans: Arrows point to the hippocampus
Magnetic Resonance Imaging (MRI) scans help diagnose Alzheimer by the shrinkage of the hippocampus (see arrow), coupled with signs of cerebral atrophy, such as deeper sulci and larger ventricles.
Cerebrospinal and other Fluid Biomarkers (14)
Amyloid and tau proteins can be detected in several biological fluids including the cerebrospinal fluid (CSF), and saliva. The most accurate correlation with Alzheimer Disease is the CSF amyloid and tau proteins. However, unlike PET scans, the fluid biomarker tests do not locate which parts of the brain are affected. Also doing a lumbar puncture to obtain CSF is uncomfortable or painful, and hence the procedure is not a popular choice.
Medical Treatment (15)
While there are no medicines that can cure Alzheimer Disease, there are a few drugs that can help in certain areas. They are described below:
In Alzheimer Disease, the neurotransmitter acetylcholine is depleted. In normal circumstances, the level of acetylcholine is kept in check by the enzyme cholinesterase that breaks down any surpluses. But since the level of acetylcholine in Alzheimer patients is already low, studies were conducted to see if preserving what remains, by inhibiting cholinesterase, can make a difference. Yes, it probably helps. People taking cholinesterase inhibitors reported improved memory, think more clearly, and it helped them with daily activities. The exact mechanism of how the medicine works is still unknown. Side effects include loss of appetite, nausea, vomiting, diarrhoea, insomnia, nightmares, and heart arrhythmias.
Glutamate is one of the most abundant excitatory neurotransmitters in our body. One of the receptors that it activates is the NMDA receptor. While glutamate is an important neurotransmitter involved in many neurological functions including memory storage, too much is deleterious, and leads to nerve death. Memantine is a NMDA receptor antagonist, and helps regulate glutamate. It improves memory and learning. Side effects include dizziness, confusion, agitation, and headaches.
Many people with Alzheimer Disease also exhibit depression, which can exacerbate the ability to think, and can make daily living very challenging. They may become even more dependent on their care partner. Selective serotonin reuptake inhibitors (SSRIs) can be prescribed for depression as well as for Alzheimer Disease. SSRIs can alleviate depression, but side effects include weight gain, drowsiness, dizziness, blurred vision and nausea. Some studies have shown that long-term use of SSRIs might reduce dementia.
Anti-anxiety Drugs (Lorazepam, Diazepam)
Some Alzheimer patients also show anxiety under certain situations; they can get upset easily, and cannot keep still in any one place. Improving the environment by avoiding bright lights, loud noises, and clearing the room, can be helpful. If not, an anti-anxiety drug might sometimes reduce stress. However, some Alzheimer patients may become more confused, or become sleepy, have difficulty swallowing, and they may be at greater risk of falling down when moving about.
If an Alzheimer patient is very aggressive, hostile, and suffer hallucinations, one might have to try one of the antipsychotic medicines. Preferably they should be used in limited situations for a short period of time. Side effects include heart problems, and some patients’ blood glucose can become elevated.
Controversial New Drug (17)
On 7 June 2021, the US Food and Drug Administration (FDA) approved a new drug, aducanumab (Aduhelm), designed to slow down cognitive decline in Alzheimer Disease. This is despite objections by the official FDA advisory committee. One of the late-stage clinical trials showed that there was no benefit. In contrast, two other trials, one on early-stage and another on late-stage Alzheimer Disease, showed that the drug helped. The FDA overruled their advisory committee and approved the drug, explaining that many Alzheimer patients were desperately wanting some form of treatment. Three members of the FDA advisory panel resigned over this issue.
Ineffective Treatments
A large number of herbal supplements, vitamins, dietary supplements have been proposed, but unfortunately none of them have been proven to work. This includes gingko biloba, vitamin E, B, and C, omega 3 fish oils, coenzyme Q10, curcumin, and polyphenols. Berries and nuts have also been advocated but they are also ineffective.
Other Therapies
Occupational and Physical Therapy
Occupational and physical therapists can help Alzheimer patients and their family in a variety of ways. These include training mobility and function, helping with communication and reasoning skills, and completing everyday tasks,. They can recommend labelling the different doors, getting hold of a dementia-friendly clock that can speak out the time and remind you what to do. They can introduce seating and mobility aids, and try out some of the newer technological aids (see below).
Speech Therapy
One of the major problems facing Alzheimer patients is their difficulty in communication, largely because of their memory loss. Speech therapy helps remind the individuals how to continue to use language. This includes repeating words, identifying pictures, and knowing what to say in different scenarios.
Music Therapy
It has often been shown that music helps Alzheimer patients by calming them down, making them feel happy. By singing songs, they are reminded of words for communication purposes. Music might also spur others into dancing, which becomes another form of exercise.
Daily Living Activities
Daily Living Activities
Daily living activities might include, socialising, regular physical exercises, mental exercises, gardening, cooking, good nutrition, adequate sleep, learning a new language, and trying out new technologies,
Playing MahjongExercising
New Technologies (18)
There are many new technologies that can help with a variety of functions, including:
Light switches that automatically switch on and off appropriately
Keyless autorecognition locks that can recognise fingerprints or voice, and can auto-lock when one leaves the home
Cookers that automatically switch off to avoid overcooking
Televisions that turn on and off automatically
Automatic reminders, like intelligent talking clocks
Artificial intelligence that can detect accidents, falls, and fever
Robots that clean the rooms
Telemedicine to consult doctors, nurses, and therapists
The number of new devices and artificial intelligence devices are increasing rapidly.
Famous People with Alzheimer Disease
Below are some well-known public figures who developed Alzheimer Disease. Sadly, there are many more.
Can Alzheimer Disease be Reversed?
Scientists from Cambridge and Leeds have successfully fully reversed age-related memory loss in mice by reconstituting chondroitin 6-sulphate to their perineuronal nets. This paves the way for developing drugs that can prevent memory loss in humans when they age (19).
Conclusions
Alzheimer is the commonest cause of memory loss. There have been many advances in the diagnosis of the condition. To date the use of two classes of drugs, the anticholinesterase inhibitors, and the NMDA antagnoists have shown some promise in improving memory. The newest drug approved by the FDA has run into some controversy. It is hoped that in future we can better understand the pathophysiology of the condition and find new drugs that can prevent or even cure the disease.
Please see the Dementia and Memory articles that complement this review (20,21).
7 Prokopenko D et al. Whole-genome sequencing reveals new Alzheimer’s disease–associated rare variants in loci related to synaptic function and neuronal development https://doi.org/10.1002/alz.12319
Where did I leave my keys? Did I switch off the lights? What am I supposed to buy?
We all forget things, and as we get older, our memory deserts us. Memory loss is something that we are going to look forward to.
The brain is the most complex structure in the known universe. There are 86 billion neurons and 100 trillion connections between these neurons. For every second of our lives, thousands of nerve cells are firing off chemicals to control nearly every aspect of what we think or do. It is the damage of these nerve cells that can cause dementia.
The commonest cause of dementia is Alzheimer Disease. This will be discussed in greater detail in the article on Alzheimer.
Definition (1,2)
Dementia is the chronic acquired decline in memory and at least one other cognitive function…
aphasia (communication)
apraxia (motor execution)
agnosia (recognition)
executive function (synthesis)
… sufficient to affect one’s daily life.
Epidemiology
The prevalence of dementia increases with age.
Age Range (years)
% Affected
65-74
5%
75-84
15-25%
>85
36-50%
Although dementia affects mainly the elderly, it is actually not a normal part of ageing. According to the World Health Organisation, worldwide, there are around 50 million people who have dementia, and each year there are nearly 10 million new cases (3).
Causes of Dementia (4)
Dementia is an umbrella term that has several causes. Below are listed some of the causes:
To verify the accuracy of the particulars, it would be good to have confirmatory information from a relative or the patient’s close friend. It might be necessary to interview the patient separately from the accompanying person.
While taking the history, one can simultaneously observe the behaviour of that person. Are they able to hear and see well, and are they behaving in the way expected for age? What were the initial symptoms? Was the memory loss like forgetting little things, forgetting appointments, or repeating the same questions? Were there any inappropriate behaviours? Did the symptoms worsen with time, and has it influenced their work and family life? Has it affected other activities like driving? One can assess their memory by asking their date of birth, their age, their address, and the name of the president or prime minister of a country.
One should ask about significant past illnesses, like high blood pressure, high cholesterol, diabetes, thyroid problems, etc. What medicines are they taking, and do they consume a lot of alcohol? Try to find out if the patient suffers from depression and anxiety. The family history should be explored, including whether other family members have Alzheimer disease, hypertension, cholesterol problems, thyroid conditions, cancer, and Huntington Chorea?
Examination
It is important to do a full general and neurological examination. Treatable causes of memory loss, like hypothyroidism, hypertension, Parkinson Disease and cancer should be excluded. The neurological examination includes how mentally alert the patient is, hearing and visual acuity, any tremors at rest, jerky movements. There may be clues during the examination that the individual is emotionally depressed or highly anxious.
A cognitive assessment should be carried out as follows:
Orientation – do they know the date, where they are?
Attention – can they recite the months of the year or spell “BREAD” backwards
Memory – can they give their home address, the name of president?
Language – can they name items in a picture, can they read a sentence from a passage and can they understand it?
Executive function – the Stroop test asks what is the color shown here: GREEN
Praxis – ask them to make alternating hand movements or imitate some gestures
Visuospatial function – draw a clock face, or overlapping pentagons.
These tests will help one decide if there is significant memory loss, and whether or not the patient needs to be referred to a psychologist for a more formal cognitive assessment.
Investigations (6)
Thyroid function, vitamin B12, folic acid, cholesterol levels, should be tested, and if human immunodeficiency virus (HIV-AIDS) or heavy metal poisoning is suspected, they should be tested as well.
An MRI Scan can show structural abnormalities and point towards Alzheimer disease, subdural haemorrhage, brain tumour, and other neurological conditions.
Proton Emission Tomography (PET) Scan can diagnose Alzheimer as well as Mild Cognitive Impairment (see Alzheimer article).
Onset of Dementia
Dementia does not come on quickly or suddenly. Instead, it is like a thief in the night that creeps up on you and over the course of years, and slowly robs you of your powers of recall bit by bit. Quite often you are unaware that your mind is going downhill, until one day you meet an old friend and cannot remember their name. It affects your work when you forget to carry out important tasks required in the workplace. You can upset your family members by failing to carry out your promises, especially if they have reminded you several times.
Mild Cognitive Impairment (MCI) (7)
Dementia is not an all or none phenomenon. It is a spectrum. When there is severe memory loss and behavioural problems, the diagnosis is clear. However, when symptoms are mild, and there may only be a few signs of dementia, but not enough to make a definitive diagnosis, then one is stuck in a limbo. This in-between state is known as Mild Cognitive Impairment (MCI) or Pre-Dementia.
MCI is further subdivided into the milder naMCI or nonamnesic MCI. These individuals are not amnesic and retain some memory. The other subdivision is the aMCI or amnesic MCI, and these people are forgetful, so they are considered slightly more severe on the dementia spectrum.
Mild Cognitive Impairment Continuum
Management
The aims of management are several. Where possible one treats the underlying disorder or diagnosis. For example thyroxine is prescribed if hypothyroid is diagnosed. Similarly vitamin B12 is administered if deficient, and one should lower blood pressure, cholesterol levels, treat diabetes, Parkinson Disease, etc. If there is a subdural haematoma, intracranial bleeding, or a brain tumour, these need to be treated appropriately.
Medical treatment to reverse or cure Alzheimer Disease is not currently available. Several medicines have been produced, and some may have short-term improvements in memory. But none of them have proven to be effective over the long-term, as judged by large-scale scientific double-blind placebo-controlled trials. Recently the USA Food and Drug Administration has approved aducanumab (Aduhelm) for Alzheimer Disease, but there is some controversy (8). Other medicines for the treatment of conditions related to Alzheimer’s are described in the article on Alzheimer Disease.
Fortunately, there are nonmedical activities that have been shown to delay or perhaps slightly improve memory loss. These include:
Social activities: Joining clubs, playing mahjong, volunteering, play with children, visit museums and art galleries, connect with social media
Exercise the brain: crossword puzzles, Sudoku, play chess, learn a new language, take up gardening, photography, birdwatching, try a new recipe, watch online zoom webinars, teach using social media platforms, travel virtually
Physical exercise: walk, swim, table tennis, yoga, walk the dog
Music: sing, play an new instrument, listen to favourite music, join a choir or instrumental group, dance
Arts and Craft: draw, paint, knit, needlework, woodwork, make jewellery, create scrapbooks and photo albums
Reading, writing, broadcasting: start a blog, a diary, write your memoirs, podcast your thoughts and writings on social media, do a regular vlog on your travels and activities
Dance-ExerciseMusic: Learning the Guitar
Conclusions
Dementia is one of the major problems confronting the elderly, and the prevalence is increasing over the years. There are many causes of dementia, and if diagnosed and treated early, one might be able to mitigate some of the undesirable consequences. Currently the best ways of slowing down dementia is through nonmedical activities, including exercise, socialising, arts and crafts.
Please see the article on Alzheimer Disease and Memory that complements this review (10,11).
I am trying to make sense of our bewildering world, attempting to unravel the mysteries of human behavior. Thinking is really tough for me. but hopefully the exercise of writing down my meandering thoughts can lead to greater insights. Come join me in this exploration of human idiosyncrasies!
Ken's Reflections 
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