Psychiatry - Theses
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ItemThe expectations and experience of a diagnosis of dementia: lessons from patients and families( 2012)Objectives: To explore the expectations of the patient and family in attending a memory clinic. In particular, do the patient and family expect, in all instances, to be told of the diagnosis? To ascertain what information is understood by the patient and carer at the feedback session, pinpointing aspects of the feedback session that were of value, locate areas of the presentation that could be improved and perhaps identify information that is not provided but could be of value. Sample: The sample was drawn from attendees at two Melbourne Memory Clinics and private patients of two associates of the National Ageing Research Institute (NARI). Methodology: The study consisted of a series of four studies. Phase I consisted of two questionnaires, one for the patient and one for the next-of-kin to complete, asking about their wants and expectations of their appointment at the memory clinic. Phase II consisted of an interview with the patient and next-of-kin at the treatment review visit. Questions related to their recall of the ‘feedback’ session, their understanding of a diagnosis of dementia and the best way to impart the diagnosis. Phase III consisted of a second interview which commenced with a recap of the first. Patient and next of kin were asked if they had changed their minds about anything they had said the first time and if they had anything to add. For Phase IV, a focus group of specialists in the diagnosis of memory disorders was conducted. Pertinent results from phases I and II were presented for discussion. Results: Phase I demonstrated that 84% of patients expected to be told of their diagnosis and 90 % wanted to be told. Their reasons for this were: to make plans/put affairs in order, to receive treatment, to get help/learn strategies to cope, “It’s my right to know/I want to know the truth”. Seventy per cent of patients thought the best way to present a diagnosis of dementia was to use a direct/straight forward approach, 11% thought a straight forward but sensitive approach was required. Seventy five per cent of next of kin thought the diagnosis should be presented in a straight forward fashion. Following a recap of this interview in Phase III, none of the respondents wanted to alter anything they had said. Psychological adjustment theory (PAT) was identified as a useful theory to explain the approach used by patients and their families in adapting to the diagnosis. During the Phase IV specialist focus group, discussion was concerned with current practice and retention of information from the feedback session. Techniques were suggested to improve patient and carer recall of the feedback session. Conclusions: The patient and their next of kin seek accurate information in order to plan their futures and manage their affairs and lifestyle even before a definitive diagnosis has been made. Gathering information, finding solutions for problems, planning and looking for support from the community are healthy strategies used by the individual to maintain self-esteem during the process of adaptation to a chronic illness. These strategies are also the building blocks of successful adaptation to a chronic illness or injury, as described by PAT.
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ItemEstrogen and neuropsychiatric disorders in later life( 2010)Experimental evidence suggests that estrogen can have both psycho- and neuro-protective effects; however this has not been consistently supported by certain clinical trials and epidemiological studies. This thesis aimed to provide a detailed investigation of the role of estrogen in later-life depression and cognitive functioning by examining serum estrogen levels, estrogen exposure across the lifetime, characteristics of hormone treatment (HT) and the role of estrogen receptor polymorphisms. Data was obtained from two longitudinal population-based studies, the 13-year Melbourne Women’s Midlife Health Project of 438 middle-aged postmenopausal women in Australia, and the seven-year Three City/ESPRIT study of 5644 older French women. Multivariate adjusted regression models showed that endogenous and exogenous hormonal characteristics late in the reproductive life can decrease the risk of late-life depression and a decline in serum estradiol levels increased the risk for recently postmenopausal women. Discontinuing HT increased the risk of depression for older women, as did the use of progestin-containing HT. Estrogen receptor polymorphisms were associated with late-life depression and can interact with HT to modify the risk of depression and mortality. Endogenous reproductive factors linked to higher lifetime estrogen exposure and high levels of estradiol in the early postmenopause were associated with better performance on certain cognitive tasks. Cognitive function also varied according to the characteristics of HT and HT reduced the risk of dementia in genetically susceptible women carrying the apolioprotein ε4 allele. This work brings some important new findings to this field of research, suggesting that the modulation of estrogen levels may be used as a possible therapeutic tool to reduce neuropsychiatric disorders and that certain subgroups of women may be genetically more susceptible to hormone modifications or to the effects of HT.