Lin Kiat Philip Yap
Email Address
mdcylkp@nus.edu.sg
Organizational Units
MEDICINE
dept
YONG LOO LIN SCH OF MEDICINE
faculty
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Publication Detecting pre-death grief in family caregivers of persons with dementia: Measurement equivalence of the Mandarin-Chinese version of Marwit-Meuser caregiver grief inventory(2018) Liew, T.M; Yap, P; Luo, N; Hia, S.B; Koh, G.C.-H; Tai, B.C; MEDICINE; DEAN'S OFFICE (SSH SCH OF PUBLIC HEALTH); SAW SWEE HOCK SCHOOL OF PUBLIC HEALTHBackground: Pre-death grief (PDG) is a key challenge faced by caregivers of persons with dementia (PWD). Marwit-Meuser Caregiver Grief Inventory (MM-CGI) and its abbreviated MM-CGI-Short-Form (MM-CGI-SF) are among the few empirically-developed scales that detect PDG. However, they have not had a Mandarin-Chinese version even though Chinese-speaking populations have among the largest number of PWD. We produced a Mandarin-Chinese version of MM-CGI and evaluated whether it had equivalent scores and similar psychometric properties to the English version. Methods: We produced the Chinese MM-CGI through the methods of forward-backward translation and cognitive debriefing. Then, we recruited family caregivers of PWD (n = 394) to complete either the Chinese (n = 103) or English (n = 291) version. The two versions were compared in their score-difference (adjusting for potential confounders using multiple linear regression), internal-consistency reliability (using Cronbach's ?) and test-retest reliability (using intraclass correlation-coefficient), known-group validity (based on the relationship with the PWD and stage of dementia) and construct validity (using Spearman's correlation-coefficient). Results: The two versions showed similar mean scores, with the adjusted score-difference of 1.2 (90% CI -5.6 to 7.9) for MM-CGI and - 0.4 (90% CI -2.9 to 2.1) for MM-CGI-SF. The 90% CI for adjusted score-difference fell within predefined equivalence-margin (±8 for MM-CGI and ± 3 for MM-CGI-SF) and indicated equivalence of the scores. The two versions also demonstrated similar characteristics in reliability and validity. Conclusions: The Chinese MM-CGI opens the way for PDG assessment and intervention among Chinese-speaking caregivers. Establishing its measurement equivalence with the English version paves the way for cross-cultural research on PDG in dementia caregiving. © 2018 The Author(s).Publication Can acute clinical outcomes predict health-related quality of life after stroke: a one-year prospective study of stroke survivors(BMC, 2018-11-21) YEOH, YEN SHING; KOH, GERALD CHOON-HUAT; TAN, CHUEN SENG; LEE, KIM EN; TU, TIAN MING; SINGH, RAJINDER; CHANG, HUI MENG; DE SILVA, DEIDRE A; NG, YEE SIEN; ANG, YAN HOON; YAP, PHILIP; CHEW, EFFIE; MERCHANT, RESHMA AZIZ; YEO, TSENG TSAI; CHOU, NING; VENKETASUBRAMANIAN, N; YOUNG, SHERRY H; HOENIG, HELEN; MATCHAR, DAVID BRUCE; LUO, NAN; Ms Yeoh Yen Shing; MEDICINE; SAW SWEE HOCK SCHOOL OF PUBLIC HEALTH; DUKE-NUS MEDICAL SCHOOL© 2018 The Author(s). Background: Health-related quality of life (HRQoL) is a key metric to understand the impact of stroke from patients' perspective. Yet HRQoL is not readily measured in clinical practice. This study aims to investigate the extent to which clinical outcomes during admission predict HRQoL at 3 months and 1 year post-stroke. Methods: Stroke patients admitted to five tertiary hospitals in Singapore were assessed with Shah-modified Barthel Index (Shah-mBI), National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Mini-Mental State Examination (MMSE), and Frontal Assessment Battery (FAB) before discharge, and the EQ-5D questionnaire at 3 months and 12 months post-stroke. Association of clinical measures with the EQ index at both time points was examined using multiple linear regression models. Forward stepwise selection was applied and consistently significant clinical measures were analyzed for their association with individual dimensions of EQ-5D in multiple logistic regressions. Results: All five clinical measures at baseline were significant predictors of the EQ index at 3 months and 12 months, except that MMSE was not significantly associated with the EQ index at 12 months. NIHSS (3-month standardized β = - 0.111; 12-month standardized β = - 0.109) and mRS (3-month standardized β = - 0.122; 12-month standardized β = - 0.080) were shown to have a larger effect size than other measures. The contribution of NIHSS and mRS as significant predictors of HRQoL was mostly explained by their association with the mobility, self-care, and usual activities dimensions of EQ-5D. Conclusions: HRQoL at 3 months and 12 months post-stroke can be predicted by clinical outcomes in the acute phase. NIHSS and mRS are better predictors than BI, MMSE, and FAB.Publication The Longitudinal Effects of Caregiver Grief in Dementia and the Modifying Effects of Social Services: A Prospective Cohort Study(Wiley, 2020-07-23) Liew, Tau Ming; Tai, Bee Choo; Wee, Shiou Liang; Koh, Gerald Choon Huat; Yap, Philip; Dr Liew Tau Ming; MEDICINE; DEAN'S OFFICE (SSH SCH OF PUBLIC HEALTH); SAW SWEE HOCK SCHOOL OF PUBLIC HEALTH; DUKE-NUS MEDICAL SCHOOLBACKGROUND: Caregivers of persons with dementia (PWD) can experience loss and grief long before the death of the PWD, with such caregiver grief postulated to affect the well-being of the PWD-caregiver dyads. However, the longitudinal effects of caregiver grief and the moderating effects of social services are not yet clear. OBJECTIVES: We investigated the longitudinal effects of caregiver grief on caregiver depression, caregivers' quality of life (QoL), and caregivers' perceived positive aspects of caregiving (PAC); and examined potential effect modification of social service utilization (dementia care services, caregiver programs, and paid caregivers). DESIGN AND SETTING: A prospective cohort study with three time points of assessments (at 0, 6, and 12 months). PARTICIPANTS: Family caregivers of community-dwelling PWD (n = 178). MEASUREMENTS: At time point 1 (baseline), participants completed questionnaires that captured caregiver grief, burden, and social service utilization. Outcomes that were captured over time were: depression (time points 1–3), QoL (time point 2), and PAC (time point 3). Caregiver grief as well as interaction terms with social service utilization were included in Tobit regression to examine the association with outcomes. RESULTS: After accounting for the effect of caregiver burden, caregiver grief remained associated with depressive symptoms (P <.001) and poorer QoL (P <.001). However, compared with burden, grief contributed to larger magnitudes of the adverse effects. Grief, not burden, was associated with less PAC (P =.006 and P =.746, respectively). In contrast, burden, not grief, was associated with poorer physical health (P =.010 and P =.110, respectively). Dementia care services attenuated the effect of burden but not grief; caregiver programs did not affect burden but appeared to aggravate the effect of grief; and paid caregivers attenuated the effect of burden, and partially attenuated the effect of grief. CONCLUSION: Caregiver grief has an impact on dementia caregivers, likely through a distinct mechanism from that of caregiver burden. However, prevailing social services may not be sufficient to address grief, highlighting the need to further train care workers in this respect. © 2020 The American Geriatrics Society.Publication Health-related quality of life loss associated with first-time stroke(PUBLIC LIBRARY SCIENCE, 2019-01-28) YEOH, YEN SHING; KOH, GERALD CHOON-HUAT; TAN, CHUEN SENG; TU, TIAN MING; SINGH, RAJINDER; CHANG, HUI MENG; DE SILVA, DEIDRE A; NG, YEE SIEN; ANG, YAN HOON; YAP, PHILIP; CHEW, EFFIE; MERCHANT, RESHMA A; YEO, TSENG TSAI; CHOU, NING; VENKETASUBRAMANIAN, N; LEE, KIM EN; YOUNG, SHERRY H; HOENIG, HELEN; MATCHAR, DAVID BRUCE; LUO, NAN; Ms Yeoh Yen Shing; MEDICINE; SAW SWEE HOCK SCHOOL OF PUBLIC HEALTH; DUKE-NUS MEDICAL SCHOOL© 2019 Yeoh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Objectives This study aimed to quantify health-related quality of life (HRQoL) loss associated with first episode of stroke by comparing patient-reported HRQoL before and after stroke onset. The impact of stroke in local population was also evaluated by comparing the pre- and post-stroke HRQoL with that of the general population. Methods The HRQoL of stroke survivors was assessed with the EQ-5D-3L index score at recruitment, for recalled pre-stroke HRQoL, and at 3 and 12 month post-stroke. Change in HRQoL from pre-stroke to 3 and 12 month was self-reported by 285 and 238 patients, respectively. Mean EQ index score at each time point (baseline: 464 patients; 3 month post-stroke: 306 patients; 12 month post-stroke: 258 patients) was compared with published population norms for EQ-5D-3L. Results There was a significant decrease in HRQoL at 3 (0.25) and 12 month (0.09) post-stroke when compared to the retrospectively recalled patients’ mean pre-stroke HRQoL level (0.87). The reduction at 3 month was associated with the reduction in all EQ-5D-3L health dimensions; reductions remaining at 12 month were limited to dimensions of mobility, self-care, usual activities, and anxiety/depression. Stroke patients had a lower mean EQ index than the general population by 0.07 points pre-stroke (0.87 vs. 0.94), 0.33 points at 3 month (0.61 vs. 0.94) and 0.18 points at 12 month (0.76 vs. 0.94) post-stroke. Conclusions Stroke has a substantial impact on HRQoL in Singapore, especially in the first three months post-stroke. Compared to the general population, stroke survivors have lower HRQoL even before stroke onset. This pre-stroke deficit in HRQoL should be taken into account when quantifying health burden of stroke or setting goals for stroke rehabilitation.Publication Profile of the Paraoxonase 1 (PON1) Gene 192Q/R Polymorphism and Clinical Associations among Older Singaporean Chinese with Alzheimer's and Mixed Dementia(S. Karger AG, 2016) Seow, Dennis CC; Gao, Qi; Yap, Philip; Gan, Jia Min; Chionh, Hui Ling; Lim, Su Chi; Feng, Lei; Ng, Tze Pin; Dr Lei Feng; MEDICINE; DEAN'S OFFICE (SSH SCH OF PUBLIC HEALTH); PSYCHOLOGICAL MEDICINEBackground: To examine the prevalence of the Paraoxonase1 (PON1) gene 192Q/R polymorphism amongst Singaporean Chinese with Alzheimer's disease (AD) and mixed dementia and possible clinical associations. Methods: We examined the presence of the PON1 192Q/R polymorphism together with cognitive status, functional status and neuropsychiatric symptoms among 186 older Singaporean Chinese with AD (n = 109) and mixed dementia (n = 77). Results: The R allele predominated in 67% of the AD patients and 63.1% of the patients with mixed dementia. Within the mixed dementia subgroup, the R allele was significantly associated with a higher BADLS score, NPI-Q scores and CDR scores. Conclusion: Among older Singaporean Chinese with AD and mixed dementia, the R allele was predominant. In particular, within the mixed dementia subgroup, the R allele carrier status was associated with poorer functional status, greater presence of neuropsychiatric symptoms and a more severe stage of dementia. Further studies should be conducted.Publication Contrasting the risk factors of grief and burden in caregivers of persons with dementia: Multivariate analysis(WILEY, 2019-02-01) Liew, Tau Ming; Tai, Bee Choo; Yap, Philip; Koh, Gerald Choon-Huat; Prof Choon Huat, Gerald Koh; MEDICINE; DEAN'S OFFICE (SSH SCH OF PUBLIC HEALTH); SAW SWEE HOCK SCHOOL OF PUBLIC HEALTH; COMMUNITY,OCCUPATIONAL & FAMILY MEDICINEBackground: Caregivers of persons with dementia (PWD) can experience loss and grief long before the death of the person. While such phenomenon of pre-death grief (PDG) has been increasingly described, we are uncertain how it can be distinct from the well-studied construct of caregiver burden. Objective: To determine whether there are differences in the risk factors of PDG and caregiver burden to aid in our understanding of the relationship between the two constructs. Methods: Spouses or children of community-dwelling PWD were consecutively sampled from two tertiary hospitals. They completed questionnaires containing a PDG scale, a caregiver burden scale, and information related to the caregiver and PWD. Risk factors of PDG and caregiver burden were identified using multivariate regression, within which PDG and caregiver burden scores were jointly included as two separate dependent variables. Results: We recruited 394 caregivers with a mean age of 53.0 years (SD 10.7), majority were Chinese (86.6%), children caregivers (86.3%), and primary caregivers (70.8%). In the regression analyses, we identified three risk factors which were shared by both PDG and caregiver burden (later stage of dementia, behavioral problems in PWD, and primary caregiving role) and three other risk factors which were unique to PDG alone (younger age of PWD, lower educational attainment of caregivers, and spousal caregiver). Conclusions: The different risk factor profiles evidence a distinction between PDG and caregiver burden. They may possibly be distilled into a framework to direct our approach to PDG interventions, which may include using caregiver burden as an opportunity to initiate conversations on grief, exploring the various aspects of losses and encouraging adaptive coping.Publication Mild Cognitive Impairment Reversion and Progression: Rates and Predictors in Community-Living Older Persons in the Singapore Longitudinal Ageing Studies Cohort(S. Karger AG, 2018) Gao Q.; Gwee X.; Feng L.; Nyunt M.S.Z.; Feng L.; Collinson S.L.; Chong M.S.; Lim W.S.; Lee T.-S.; Yap P.; Yap K.B.; Ng T.P.; MEDICINE; PSYCHOLOGICAL MEDICINE; DUKE-NUS MEDICAL SCHOOLBackground: Studies report varying rates and predictors of mild cognitive impairment (MCI) progression and reversion. Methods: We determined MCI reversion and progression among 473 community-living adults aged ?55 years in the Singapore Longitudinal Ageing Study with an average of 6 years of follow-up and estimated association with baseline variables. Results: A total of 208 MCI participants reverted to normal cognition (44.0%) and 19 progressed to dementia (4.0%). In a model adjusted for age, gender, education, ethnicity, cardiovascular risk factors/diseases, APOE ?4 status, depressive symptoms, leisure-time activities (LTA), and baseline Mini-Mental State Examination (MMSE), we found that LTA score (OR = 1.07, 95% CI 1.02–1.13), MMSE score (OR = 1.21, 95% CI 1.11–1.31), and subjective memory complaint (OR = 1.83, 95% CI 1.16–2.90) significantly predicted MCI reversion. Controlling for all variables, age (OR = 1.09, 95% CI 1.02–1.17), lower education (OR = 3.26, 95% CI 1.01–10.49), and the metabolic syndrome (OR = 3.13, 95% CI 1.12–8.77) significantly predicted MCI progression. Controlling for age, sex, ethnicity, and education, diabetes significantly predicted MCI progression (OR = 3.19, 95% CI 1.23–8.26), but the presence of other cardiometabolic factors reduced this association to an OR of 2.18 (95% CI 0.72–6.60). Conclusion: In this relatively younger population, there were higher rates of MCI reversion and lower rates of MCI progression which were predicted by the positive effects of LTA and a higher MMSE score as well as by the deleterious effect of the metabolic syndrome and diabetes. © 2018 The Author(s) Published by S. Karger AG, BaselPublication Deployment of assistive living technology in a nursing home environment: Methods and lessons learned(2013) Aloulou, H; Mokhtari, M; Tiberghien, T; Biswas, J; Phua, C; Kenneth Lin, J.H; Yap, P; MEDICINEBackground: With an ever-growing ageing population, dementia is fast becoming the chronic disease of the 21st century. Elderly people affected with dementia progressively lose their autonomy as they encounter problems in their Activities of Daily Living (ADLs). Hence, they need supervision and assistance from their family members or professional caregivers, which can often lead to underestimated psychological and financial stress for all parties. The use of Ambient Assistive Living (AAL) technologies aims to empower people with dementia and relieve the burden of their caregivers.The aim of this paper is to present the approach we have adopted to develop and deploy a system for ambient assistive living in an operating nursing home, and evaluate its performance and usability in real conditions. Based on this approach, we emphasise on the importance of deployments in real world settings as opposed to prototype testing in laboratories. Methods. We chose to conduct this work in close partnership with end-users (dementia patients) and specialists in dementia care (professional caregivers). Our trial was conducted during a period of 14 months within three rooms in a nursing home in Singapore, and with the participation of eight dementia patients and two caregivers. A technical ambient assistive living solution, consisting of a set of sensors and devices controlled by a software platform, was deployed in the collaborating nursing home. The trial was preceded by a pre-deployment period to organise several observation sessions with dementia patients and focus group discussions with professional caregivers. A process of ground truth and system's log data gathering was also planned prior to the trial and a system performance evaluation was realised during the deployment period with the help of caregivers. An ethical approval was obtained prior to real life deployment of our solution. Results: Patients' observations and discussions allowed us to gather a set of requirements that a system for elders with mild-dementia should fulfil. In fact, our deployment has exposed more concrete requirements and problems that need to be addressed, and which cannot be identified in laboratory testing. Issues that were neither forecasted during the design phase nor during the laboratory testing surfaced during deployment, thus affecting the effectiveness of the proposed solution. Results of the system performance evaluation show the evolution of system precision and uptime over the deployment phases, while data analysis demonstrates the ability to provide early detection of the degradation of patients' conditions. A qualitative feedback was collected from caregivers and doctors and a set of lessons learned emerged from this deployment experience. (Continued on next page) (Continued from previous page). Conclusion: Lessons learned from this study were very useful for our research work and can serve as inspiration for developers and providers of assistive living services. They confirmed the importance of real deployment to evaluate assistive solutions especially with the involvement of professional caregivers. They also asserted the need for larger deployments. Larger deployments will allow to conduct surveys on assistive solutions social and health impact, even though they are time and manpower consuming during their first phases. © 2013 Aloulou et al.; licensee BioMed Central Ltd.Publication Metabolic syndrome and amnestic mild cognitive impairment: Singapore longitudinal ageing study-2 findings(IOS Press, 2013) Feng, L.; Chong, M.S.; Lim, W.S.; Lee, T.S.; Collinson, S.L.; Yap, P.; Ng, T.P.; MEDICINE; PSYCHOLOGY; DUKE-NUS GRADUATE MEDICAL SCHOOL S'PORE; PSYCHOLOGICAL MEDICINEMetabolic syndrome (MetS) is reported to be associated with cognitive decline and dementia, in particular vascular dementia. However, the evidence linking MetS to Alzheimer's disease (AD) and amnestic mild cognitive impairment (aMCI), a precursor of AD, is inconsistent and limited. This study examined the association of MetS and its components with aMCI and how APOE-εe4 and younger age influenced this association. Participants with aMCI (n = 98) and cognitively normal controls (n = 802) were identified from baseline data in a second wave cohort of older subjects aged 55 and over in the Singapore Longitudinal Ageing Study-2 (SLAS-2) in 2009/2010. The associations of MetS and its individual components with aMCI were analyzed using logistic regression controlling for age, gender, education, current smoking, alcohol drink, leisure time activities score, Geriatric Depression Scale score, APOE-ε4, and heart disease or stroke. The analysis was repeated for associations stratified by age and APOE-ε4 status. In multivariate analysis, MetS was associated with an elevated risk of aMCI (OR = 1.79; 95% CI 1.15-2.77). Among MetS components, central obesity showed a significant association with aMCI (OR = 1.77; 95% CI 1.11-2.82). The association between MetS and aMCI remained significant on repeated analysis among subjects free of heart disease and stroke. This association was particularly stronger among participants with APOE-ε4 allele (OR = 3.35; 95% CI, 1.03-10.85) and younger (<65 years) participants with APOE-ε4 (OR = 6.57; 95% CI, 1.03-41.74). MetS was found to be associated with aMCI, especially in individuals with APOE-ε4 at younger age in this middle-aged and older cohort. © 2013 - IOS Press and the authors. All rights reserved.Publication Role of caregiver factors in outpatient medical follow-up post-stroke: observational study in Singapore(BMC, 2021-04-14) Tyagi, Shilpa; Koh, Gerald Choon-Huat; Luo, Nan; Tan, Kelvin Bryan; Hoenig, Helen; Matchar, David B; Yoong, Joanne; Chan, Angelique; Lee, Kim En; Venketasubramanian, N; Menon, Edward; Chan, Kin Ming; De Silva, Deidre Anne; Yap, Philip; Tan, Boon Yeow; Chew, Effie; Young, Sherry H; Ng, Yee Sien; Tu, Tian Ming; Ang, Yan Hoon; Kong, Keng He; Singh, Rajinder; Merchant, Reshma A; Chang, Hui Meng; Yeo, Tseng Tsai; Ning, Chou; Cheong, Angela; Ng, Yu Li; Tan, Chuen Seng; Prof Choon Huat, Gerald Koh; DEAN'S OFFICE (MEDICINE); CENTRE FOR MOLECULAR EPIDEMIOLOGY; MEDICINE; DEAN'S OFFICE (SSH SCH OF PUBLIC HEALTH); DEAN'S OFFICE (DUKE-NUS MEDICAL SCHOOL); SAW SWEE HOCK SCHOOL OF PUBLIC HEALTH; DUKE-NUS MEDICAL SCHOOL; COMMUNITY,OCCUPATIONAL & FAMILY MEDICINEBackground: Outpatient medical follow-up post-stroke is not only crucial for secondary prevention but is also associated with a reduced risk of rehospitalization. However, being voluntary and non-urgent, it is potentially determined by both healthcare needs and the socio-demographic context of stroke survivor-caregiver dyads. Therefore, we aimed to examine the role of caregiver factors in outpatient medical follow-up (primary care (PC) and specialist outpatient care (SOC)) post-stroke. Method: Stroke survivors and caregivers from the Singapore Stroke Study, a prospective, yearlong, observational study, contributed to the study sample. Participants were interviewed 3-monthly for data collection. Counts of PC and SOC visits were extracted from the National Claims Database. Poisson modelling was used to explore the association of caregiver (and patient) factors with PC/SOC visits over 0–3 months (early) and 4–12 months (late) post-stroke. Results: For the current analysis, 256 stroke survivors and caregivers were included. While caregiver-reported memory problems of a stroke survivor (IRR: 0.954; 95% CI: 0.919, 0.990) and caregiver burden (IRR: 0.976; 95% CI: 0.959, 0.993) were significantly associated with lower early post-stroke PC visits, co-residing caregiver (IRR: 1.576; 95% CI: 1.040, 2.389) and negative care management strategies (IRR: 1.033; 95% CI: 1.005, 1.061) were significantly associated with higher late post-stroke SOC visits. Conclusion: We demonstrated that the association of caregiver factors with outpatient medical follow-up varied by the type of service (i.e., PC versus SOC) and temporally. Our results support family-centred care provision by family physicians viewing caregivers not only as facilitators of care in the community but also as active members of the care team and as clients requiring care and regular assessments.