By Charles J.C., MBBS
National Hospital of Sri Lanka
Dementia is a growing public health problem affecting 50 million people globally with 7.7 million new cases diagnosed each year. It is the fifth leading cause of death worldwide. In simple terms, dementia refers to progressive memory loss, resulting in loss of control over previously familiar tasks and an increasing inability to recognize familiar surroundings and people. Dementia is characterized by deterioration in cognitive function (ability to process thoughts) and impaired memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgement. Thus, it causes significant social, occupational, psychological and behavioural impairment.
Dementia usually occurs in the elderly, around the age of 65 years, when the prevalence of dementia is 6-14%. Each five years prevalence doubles; at 85 years of age, prevalence is around 35%. Risk factors for dementia include social isolation, presence of multiple non-communicable diseases (diabetes, high blood pressure, high cholesterol levels, etc.), low educational status, low nutritional status, pathologies involving the brain, psychiatric illness (e.g. schizophrenia), poor blood pressure control, non-use of hormone replacement therapy and illicit drug use. The most common causes of dementia are Alzheimer’s disease (60%) and mini strokes (20%). Other causes include Lewy body dementia, Parkinson’s disease and rarer causes. In younger persons with memory loss, other sinister causes need to be sought.
Alzheimer’s disease results from neurodegeneration, partly due to aging. Aging is a strong independent risk factor but every elderly person will not be affected; a genetic component confers 5% risk. Meanwhile, stroke occurs in the presence of multiple co-morbidities such as diabetes, high blood pressure and high cholesterol levels. As these non-communicable diseases are more prevalent in the elderly, the risk of mini stroke is much higher in the aging population.
Dementia severely affects quality of life and activities of daily living (ADL), with detrimental effects on both the patient and family. The confidence and self-esteem of persons affected with dementia are often broken by the disease, leading to mood fluctuations, anxiety, and depression. Even highly independent people become dependent on their caregivers. Difficulties in adjusting to the changing caregiving role and withstanding the emotional and economic burden of dementia is common within affected families. Caregivers cope by using a range of interventions, from simple cognitive exercises and environmental modification to adding medications to counter behavioral problems.
A particularly challenging behavioural problem is the tendency to fill gaps in memory by making up stories or “confabulation.” For example, in response to the question, “How did you come to hospital?” a patient may respond “bus” or any other plausible mode of transport, simply because they cannot remember how they arrived at the hospital. Younger caregivers may perceive this as purposeful lying by elders, often leading to emotional outbursts, neglect or abuse.
The burden on carers is often overwhelming but remains largely unaddressed. Apart from the emotional toll, healthcare expenses may be high as a result of spending on transport, missed work, bystander expenses, and home-based nursing. Lack of financial assistance and family support add to the stress of caregiving, which progresses from helping to fill gaps in memory or searching for misplaced items to money management and total dependence, while juggling one’s own commitments.
Spouse carers and females are more subjected to caregiving burden, with depression reported in over two-thirds of carers. Poor selfcare, a higher incidence of hypertension, dyslipidemia, reduced immune function and longer duration of respiratory tract infections have been observed in carers. With terminal dementia, institutionalizing the patient, when required, and ultimately losing the patient, will necessarily have a significant impact on carers. Some are haunted by guilt, even after the patient passes away, due to neglect or substandard care. Carers need financial, social, emotional and health support to overcome all these hurdles.
Multidisciplinary team management is needed to treat dementia involving neurologists, psychiatrists, general physicians, primary care physicians, nurses, social workers and occupational therapists. Though inpatient care is required, in most instances community-based care is crucial to facilitate understanding and intervening to address family dynamics and the home environment. In Sri Lanka, there is a major gap in community-based services, an aspect that needs to be explored specifically in relation to dementia management, and, more broadly, with respect to elderly care.
Many high-income countries have national dementia policies in preparation for the growing number of people living with dementia. The World Health Organization (WHO) declared dementia a public health priority in 2017 to increase awareness, support systems, and global initiatives to address the disease burden. WHO has also launched an international surveillance platform, Global Dementia Observatory, which includes guidelines and checklists to facilitate dementia preparedness at the country level (https://www.who.int/mental_health/neurology/dementia/Global_Observatory/en/). Among them, are valuable tools for carers, such as iSupport–a manual for carers of people living with dementia (https://www.who.int/mental_health/neurology/dementia/isupport_manual/en/).
Dementia has a significant on healthcare systems, particularly with respect to expenditures; about 1% of GDP is spent on dementia globally, mostly in high-income countries. The average duration of hospital stays of people with dementia is long compared to other diseases and at least 10 times more than any other diagnosis considered. Because dementia is not an acute life-threatening problem, it does not receive the attention it should, particularly in countries like Sri Lanka that lack financial and human resources to establish multi-professional primary care teams and basic infrastructure for long term management of dementia. However, this situation will likely change in future owing to the growing disease burden, and its wide-ranging impacts on health and productivity.
Though definitive treatment has not arrived yet, many therapies are currently under investigation. As neuronal loss cannot be replaced by new cells, the scope of extant treatment is to slow the rate of neuronal loss and counter behavioural problems. Early diagnosis and optimal management will improve quality of life and reduce the carer burden.
At present, people living with dementia have little support in Sri Lanka. Aside from the Lanka Alzheimer’s Foundation, few formal support systems exist in the country, with even less in the peripheries. Establishing community-based long-term care for elders along with respite care for carers are much needed initiatives that would need to be evaluated by the public health sector as part of a national programme on dementia preparedness in Sri Lanka.
The aim of this article is to increase awareness on dementia and, in particular, highlight the burden on carers as well as the absence of support services for affected families in Sri Lanka.
An air of discontent prevails
We have had a series of “Avurudhu parties” here in Aotearoa. No shortage of Kavum, Kokis, Athiraha, and even Wali Thalapa. Buffalo curd available locally and of course imported treacle in abundance. Yours truly has assumed the role of a fly on the wall during these festivities and gleaned much information, worth talking about.
First to get on to the Pearl, the talk of the botched-up vaccination plan and running out of the second dose of vaccine. Bizarre permutations as to what would happen if the second dose was not available on time and to who would be press-ganged into getting the “dodgier” types of vaccine from China and Russia, etc. The possible repercussions of getting a second dose of another type of vaccine to the original, the speculations of which left me rather glad that the general populace of Aotearoa has not been vaccinated to date. The talk moved on to the Easter bombings and the recent comments by leaders of the Roman Catholic church as to the possible perpetrators of the attack. Some increasingly obvious conclusions as to those responsible for the planning and funding of same are being reached by those other than some of us who dared to voice our opinions over a year ago! This combined with the increasing and very rapid unpopularity of the person they elected to high office hoping he was genie of the magic lamp type, and the possible reverse of Hong Kong that could take shape on the reclaimed land near the Colombo port, does not bode well for an already dubious future. By reverse of Hong Kong, I mean Hong Kong is trying to hold out as a bastion for democracy, whilst the proposed port city seems to be modeled on the opposite!
Moving on to Aotearoa, the rest of the world seems to be praying for a leader such as our own Jacinda Ardern, but the fat cats of Aotearoa are getting rather sick of her. Those who own multiple houses and have been setting off their interest payments against their taxes due to a loophole in the law that has now been plugged are grumbling. The fact that most young people can’t afford to buy their first houses due to rich people and property developers snapping up all available property, happily funded by banks who are only interested in the bottom line, is of no consequence to them. The fact that this could lead to so much discontent that it could even lead to armed insurrection doesn’t bother them. They seem to have forgotten that we have had almost no deaths and hardly any Covid 19 cases in our community when they say that the lockdowns, we underwent were too excessive and how the economy and business sector has suffered. These very people throng the stadia during the rugby and cricket games and enjoy music concerts with gay abandon. Megacorporations are not happy about the restrictions that are coming on with regard to the use of Liquid Petroleum Gas (LPG) due to environmental concerns. To top it all off I had a lecture from my 13-year-old daughter about how I am being “led by the nose” by Jacinda Ardern and her propaganda! Where she got that from could only be from her elder brothers whose get rich quick schemes have seen a setback due to certain leftist policies coming in from the Labour government that is in power with an absolute majority.
I laugh to myself and think about other examples I have seen of self-proclaimed pundits never being content with their lot. My education was in a very large Government school. As a perfect and a member of some sports teams we handled the administration and some of the governance of this school. Later in life when my children were attending a private school I got involved in the Executive committee of the PTA of that school. The “problems” faced by the private school and the vast dramas that were involved in trying to solve those problems were laughable when compared to those faced by even us, senior students (a much lower level in the administration) of the Government school.
It led me to believe that people always grumble. They are never content with their lot and there is always someone plugging their case and trying to sow the seeds of discontent among the populace. If those living in Aotearoa, in the present situation and well aware of the chaos and mayhem that is prevailing in the rest of the world are dissatisfied, when will anyone be satisfied? Everything is relative and one should try to step outside the confines of one’s own situation and look at the broad picture. In the words of learned barristers, I rest my case!
This week’s missive will not be complete without a tribute to the memory of Prince Phillip, the Duke of Edinburgh. He lived through some of the best and worst times of human existence on this planet and conducted himself impeccably. He showed his humanity and his failings, with a few bloopers down the line but most of those had an undercurrent of humor and couldn’t really be construed as offensive, despite the best efforts of the media and others to make them so. He served as consort to her Majesty the Queen with loyalty and aplomb and he leaves behind an enviable legacy in the world of conservation and youth affairs. It is hoped that his heirs will be up to the task for they face a task which in cricketing terms could be classed as coming into bat after the great Sir Vivian Richards had just scored a century, in his prime. Something very difficult to surpass in skill and entertainment value. Unfortunately, the Duke made just 99. May he rest in peace!
We have much to learn; and emulation is no disgrace
“Imitation is the sincerest form of flattery that mediocrity can pay to greatness.” said Oscar Wilde who, through sharply ironic wit, often proclaimed the absolute truth.
Cassandra quotes him today as she wants to point out how much we in Sri Lanka can benefit by reaping some ideas from the recent royal funeral in Windsor. And she does not excuse herself for placing stress on our mediocrity as juxtaposed with greatness. Nationalists may shout themselves hoarse and bring down a few more majestic trees by decrying the comparison. They can justifiably claim we have a cultural heritage of two and a half millennia but have we remained cultured, following faithfully and correctly the four great religions of the world? A loud NO from Cass, echoed by millions of others. Though Britain’s development of the English language, culture, arts and science was later than our civilization, they outstripped all countries at one time and are again elevated, while we are poised on bankruptcy, with the begging bowl in hand and thugs and thieves as legislators. We in Sri Lanka are mediocre if not degraded against the greatness shown by the Brits in many spheres. This is no Anglophile speaking but a dame who was born when the Brits were leaving us to govern ourselves and grew up with our statesmen doing a jolly good job of it; Sinhalese, Tamil, Burgher, and a few Muslims taking the lead graciously and effectively with complete honesty, to serve the people. They maintained and improved our country so it was admired by others and even some desiring to imitate Ceylon as Singapore’s Lee Kwan Yew admitted. And where are we now? Except the Rajapaksa family from Medamulana, wearing rose tinted glasses or with eyes shut by arrogance, and their followers and throngs of sycophants, others see our country and our people for what it, and the people, really are. No need to elaborate.
The funeral of Prince Philip juxtaposed against customs here
The low-key funeral observing all Covid-19 restrictions was noteworthy for being utterly devoid of bombast and vainglory. It was dignified and moving. Cass wonders how many of her readers watched the funeral on Saturday 17, late evening here. Prince Philip had detailed all arrangements from the Navy being prominent and other Forces joining in plus the substitution of the gun carriage with a jeep he had helped design. The horse carriage he was adept at racing was stationed close by the entrance to the chapel. He has bequeathed it to the daughter of his youngest son and Sophie; the Wessexes having been very close to him and the Queen.
The entire proceedings proved first and foremost that the royal family observed strict pandemic restrictions like mask wearing and physical distancing. There was no one rule for them and another rule for us, thus proving beyond doubt that England (usually), and more so the Royal Family (definitely) are a country and an institution despising double standards. The monarch decreed and abided by the same regulations that have restricted everyone else in the UK, sharing their fate. An anecdote is relevant here. The Queen learned that lesson long ago. She was 14 when her mother said, after Buckingham Palace was bombed in September 1940, that she “could look the East End in the face now.”
Do all our people follow rules common to everyone? Oh! My heavens NO! There are differentiations according to layers in society. Shangri La would host a party for a hundred when only 30 are allowed to gather. During the height of the first wave when restrictions were strict, SLPP electioneering saw hordes thrust together and baby carrying, patting heads and hand clasping mostly by Mahinda Rajapaksha sans a mask. He has a charismatic bond with the masses but that needed to be curbed. Sajith Premadasa’s meetings were strict on physical distancing and mask wearing.
Only 30 were invited to the extremely solemn and yes, beautiful funeral service at Windsor Chapel. This meant eliminating even close relatives of the Family; but it was done. The Queen sat distanced from her daughter and sons and their spouses. Her now diminutive figure seated alone emphasized the loneliness she must be feeling after a close and successful marriage of 73 years.
This brings to mind our First Ladies. Cass steps out bravely to say that Elina Jayewardene was a gracious lady of restraint and dignity, the only perfect consort so far. Cass remembers Hema Premadasa beating her breast (true) and crying over the coffin of her late husband’s remains – in the true sense of the word – at the Prez’s funeral at Independence Square. There is dignity in restraint of even tears over a death in public. Among the women Heads of the country, the mother completely beat the daughter in dignity and ability.
We Sri Lankan women are now much more restrained in our mourning at funerals. Time was when widows even hoarsely wailed their sorrow, coiled and roiled with grief, and begged the dear departed “To look once more; say one word.” Cass in all the expressed grief of such funerals suppressed her laughter with difficulty. How would it be if the corpse obliged?
The choir at the funeral of Prince Philip was just four – one woman and three men. But their singing resounded in the high vaulted, completely majestic, centuries old church. The lone kilted piper within the Chapel evoked much. The service itself was short, just a Reading, prayers and listing of the multitude of honours bestowed on the Duke of Edinburgh, whose medals and decorations were on display beside the alter. The Archbishop of Canterbury, Justin Welby, and the Dean of Windsor, David Conner conducted the service.
To conclude, the Duke of Edinburgh had advised and laid stipulations on a simple funeral with the necessary pomp and pageantry but low key and very unostentatious. The actual funeral was even more low-key with mourners requested not to be on the streets or place flowers. The latter they did in all the residencies of the Royal Family in appreciation of a man who faithfully stood by the Queen and in his own way gave service to the nation.
Coming back to Free Sri Lanka, we seem to stress on that first word Cass inserted to the country name, even in these dire times of no crowds. And the worst is milling crowds are apparently encouraged to boost popularity of certain VVIPs by sycophants and by the preference/orders of the VVIP himself.
Consider the funeral of Minister Thondaman: crowds in Colombo and all VIPs wishing to register their presence before the body, and then the commotion at the actual cremation Up Country. Consider this year’s Sinhala New Year celebrations which were very dignified at the President’s residence but were inclusive of all traditions and a large gathering in the PM’s home, even raban playing by the Second Lady, and milling crowds outside.
Roller coaster ride of the country continues
Cass is relieved she had a topic to write on; namely that we should emulate the manner in which the much admired Duke of Edinburgh’s funeral was conducted, abiding by his stricture of it being low key and the country’s Covid restrictions. Our leaders especially must accept the saying I quoted at the beginning.
The country continues its roller coaster bumpy ride with some crying out the country is being sold to the Chinese, we will be a colony of theirs after they occupy the Port City; and others in remote areas sitting down for days on end, some near 100 days, drawing attention to the human elephant conflict. Much is touted about the Bill relating to the rules to govern the Port City.
Cassandra listens to all, and is somewhat warned and frightened, but cannot comment. However, one matter she speaks about loud and clear. The people must be told the status quo of the pandemic – daily numbers catching the infection and numbers dying. This is not for interest sake or ghoulish appetites; but to know how things are so we relax a wee bit or shut in more stringently. The Covid-19 Task Force, or the Health High Ups (not Pavithra please) should tell the country of the true situ of the pandemic as it holds the country in its grip. We want to know whether the grip is tightening or weakening. Please give us daily statistics. This newspaper announces total numbers. No help. Are we expected to jot down figures, subtract, and give ourselves daily infection and death statistics? No! It goes to prove that other matters – political slanted, ego boosting and economics – are more important than warning, containing the pandemic, and saving lives.
Do you pump Octane 95 Petrol to your car to get better performance?
If your answer is YES, this article is for you
Dr. Saliya Jayasekara.
Senior Lecturer Department of Mechanical Engineering
University of Moratuwa
Many passenger vehicles, including three-wheelers and motorcycles are fueled by octane 95 gasoline when octane 92 gasoline (petrol) is available at a lower price.
Otto engine (petrol engine) is an internal combustion spark ignition engine invented by a German engineer Nicolaus Otto in 1876 and used in most of the light weight vehicles including cars, three wheelers and motor bicycles. Otto engines can burn most of the hydrocarbon fuels (including hydrogen and ethanol) that can mix with air by evaporation (low boiling point). But the combustion characteristics of different hydrocarbons are not the same when burned inside an engine. If an Otto engine is designed for a particular fuel, it would not perform similarly with a fuel that has a different chemical composition.
In a well-tuned Otto engine run on gasoline for which the engine is designed, the combustion of the gasoline (petrol) / air mixture will continue smoothly from the spark plug to the piston head by igniting successive layers of the mixture as shown in Figure 1 (a).
If low grade gasolines are used, the combustion of some of the air/ fuel mixture in the cylinder does not result from propagation of the flame front initiated by the spark plug, but one or more pockets of air/fuel mixture explode (Detonate) outside the envelope of the normal combustion front as shown in Figure 1 (b). This detonation can cause severe damage to the piston and the head of the engine while deteriorating thermal performance of the engine (low efficiency)
Gasoline is a petroleum-derived product comprising a mixture of different hydrocarbons ranging from 4 to 12 carbon atoms in a carbon chain with the boiling point ranging of 30–225°C. It is predominantly a mixture of paraffins, naphthenes, aromatics and olefins. Additives and blending agents are added to improve the performance and stability of gasoline. The engine designers learned that straight-chain paraffin have a much higher tendency to detonate than do branched-chain paraffin.
The tendency of a particular gasoline to detonate is expressed by its octane number (ON). Arbitrarily, tri-methyl-pentane, C8H18 (iso-octane) is assigned an ON of 100, while the straight-chain paraffin n-heptane, C7H16 is given an ON of zero. Hence, a fuel sample with the same anti-detonation quality as that of a mixture containing 90% iso-octane and 10% n-heptane is said to have an ON of 90. Gasoline is made up of a mixture of mostly branched-chain paraffin with suitable additives to give an ON in the range 90 –100. It was also learned through experiments that the ON of a gasoline blends (e.g. gasoline and ethanol) can be calculated by using weighted average ON of each compound. Most importantly, the octane number has nothing to do with the heating value (Calorific value) or the purity of the fuel.
Engine thermodynamics show that engines with a high compression ratio offer higher thermal performance than engines with a low compression ratio. These engines having high compression ratio require high octane gasoline (for example octane 95) to avoid detonation. However, using gasoline having higher octane ratings for the engines designed for a low octane rating (for example, 92 octane) would not provide an additional benefit or loss, other than increased fuel cost.
Therefore, it is important to know the designed octane number of the engine before fueling (refer owner’s manual of the vehicle). For example: the minimum ON requirement for two and three wheelers in south Asia is 87 (The World Bank). Most of the Toyota, Honda and Nissan models including hybrid engines recommend 92 octane gasoline.
Dr. Saliya Jayasekara received the B. Sc. degree in mechanical engineering from university of Moratuwa in 2001, and the M.Sc. and PhD degrees in decentralized power generation systems from Royal institute of technology Sweden and the Melbourne University Australia in 2004 and 2013 respectively. He has well over 13 years of national and international experience in design and installation of centralised/decentralised power plants, boilers (utility/package) and heat exchangers. Currently he is serving as a senior lecture at University of Moratuwa, a visiting lecturer and fellow at Deakin University Australia.
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