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dementia psychosis elderly

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dementia psychosis elderly

The evaluation was prioritized according to clinical acuity and intervention impact, as indicated by the history and initial examination. Concurrently, other co-occurring psychiatric conditions associated with psychosis, such as depression and Alzheimer’s type dementia, were evaluated and managed. According to her son, Ms. A had had “strange thoughts” for as long as he could remember. Baldwin RC: Delusional depression in elderly patients: characteristics and relationship to age at onset. When her husband died 5 years ago, Ms. A developed a major depressive disorder, single episode, severe with psychotic features. Progressive treatments involved maximizing nonpharmacologic interventions while judiciously using sequential, minimal but effective doses of psychotropic medications for specific target symptoms. The patients (or their health care proxies) and the treatment team must be aware of the pros and cons of usual treatments, alternative interventions, and no treatment. Their clinical effectiveness may be more apparent when these drugs are discontinued, such as due to a lack of perceived positive effect or because of side effects. Nonpharmacologic approaches included individual, group, and family psychotherapies, expressive therapies such as art and music therapy, behavioral and milieu interventions, and case management (14 , 15) . The signs and symptoms of such co-occurring conditions became clearer as other conditions, such as the delirium, remitted. The cholinesterase inhibitors are known to increase gastric acid secretion, which might cause Ms. A more discomfort, despite her taking medication for gastroesophageal reflux disease. From the initial interview and mental status examination, we can judge that there were three leading conditions that may have been contributing to Ms. A’s presentation of paranoid delusions, visual hallucinations, restlessness, and difficulty in being redirected: delirium; major depressive disorder, recurrent, severe with psychotic features; and dementia with delusions, depressed mood, and behavioral disturbance. For Ms. A, appropriate simplification of the medication regimen and treating a urinary tract infection, constipation, hypothyroidism, and pain helped clear the delirium and improve her clinical state. Discerning and managing psychotic symptoms among elderly patients and residents can be challenging for healthcare professionals and accelerate caregiver burnout. Because she presented with a clouded sensorium, which supported a diagnosis of delirium, a diagnosis of a psychotic disorder due to a general medical condition could not be fully supported at initial presentation. Paranoia refers to a feeling of extreme suspicion, with a patient believing that caregivers or others are trying to poison him, steal from him, physically harm him, or are just generally bad people with a sinister purpose. Psychosis Due to Alzheimer’s Type Dementia. Ballard C, Howard R: Neuroleptic drugs in dementia: benefits and harm. ECT, considered a treatment of choice for depression with psychosis, was not pursued because the potential risks, such as increased confusion, outweighed the potential benefits, especially since Ms. A responded well to low dosages of antidepressant and antipsychotic medications. By clicking Sign Up, I understand and agree to the Privacy Policy and Terms of Use. In contrast to the cholinesterase inhibitors, memantine, with its low incidence of relatively minor side effects, seemed to be a better choice. Misuse or abuse of potentially addictive prescription drugs (benzodiazepines, opiates, and the like) and other drugs cited in the updated Beers criteria (4) for potentially inappropriate medication use in the elderly is of growing concern, as many elderly hospital admissions may be related to medications or toxic effects of medications. The management of psychosis in the elderly is a multidisciplinary endeavor that includes concurrent pharmacologic and nonpharmacologic medical-psychiatric evaluation and interventions. Int J Geriatr Psychiatry 1995; 10:981–985Google Scholar, 12. In many elderly persons, it is within the context of frailty, limited reserve capacity, and increased vulnerability to adverse outcomes from stressors (18) that several interconnecting pathological mechanisms lead to psychosis. After reviewing Ms. A’s clinical condition and medications further, it was judged that the aspirin might be causing her abdominal discomfort, despite the use of medication for gastroesophageal reflux disease. Br J Psychiatry 1987; 151:324–332Google Scholar, 11. Free T 4 and total T 3 were low, with an elevated thyroid-stimulating hormone level. The choice and dosing of medications for elderly patients is guided not only by efficacy but primarily by potential adverse interactions with other medications or illnesses, susceptibility to unwanted side effects, and the usefulness of some side effects for certain patients (for example, an antipsychotic that increases appetite may be desirable for a patient with weight loss due to anorexia). In her current situation, it was judged that the risks outweighed the benefits of continuing on aspirin therapy, and the aspirin was discontinued. Visual hallucinations mean the patient is seeing things others are not. 1, No. Delusions and hallucinations in people with dementia occur episodically and may persist. The case of Ms. A illustrates the complex, multifactorial, and changing nature of psychosis in the elderly. Ms. A’s urinalysis with cultures and sensitivities revealed an Escherichia coli urinary tract infection. Ms. A was worked up and treated for conditions that can cause delirium, such as inappropriate drug use, withdrawal from drugs, infection, urinary retention, constipation, physiologic abnormalities, cardiovascular problems, intracranial strokes, seizures or hemorrhages, and sensory deprivation. Edlund A, Lundstrom M, Sandberg O, Bucht G, Brannstrom B, Gustafson Y: Symptom profile of delirium in older people with and without dementia. Ms. A also had a history of recurrent urinary tract infections, chronic constipation, frequent falls, and osteoporosis. Initial mental status examination revealed Ms. A to be an unkempt, distraught, elderly woman with poor eye contact and poor attention span. Wikibuy Review: A Free Tool That Saves You Time and Money, 15 Creative Ways to Save Money That Actually Work. In addition, Ms. A had gastroesophageal reflux disease. Symptoms of dementia-related psychosis occur episodically, and the nature and duration of episodes vary between patients and across dementia types. Jeste DV, Sable JA, Salzman C: Treatment of late-life disordered behavior, agitation, and psychosis, in Clinical Geriatric Psychopharmacology, 4th ed. These symptoms make it is all too common for cases of abuse to be dismissed when reported by a person suffering from dementia. The differential diagnosis in an elderly patient such as Ms. A who presents with delusions, hallucinations, and behavioral disturbance can include psychosis related to delirium, general medical conditions, affective illness, dementia, schizophrenia or other primary psychotic disorders, and substance abuse or dependence. Because of modest efficacy and minimal effectiveness of most psychotropic agents in managing behavioral disturbances, multiple drugs are often used in the hope that there will be some combined efficacy. Dr. Whitfield has received research support from AstraZeneca and NIH. To treat the infection, Ms. A received antibiotics according to the results of the urine culture antibiotic sensitivities. What is the Connection Between Alzheimer's and Psychosis. Pertinent findings are discussed in conjunction with associated interventions in the next section. As Ms. A’s delirium cleared, she became more lucid, focused, and coherent in her conversation. Consistent with infection, the CBC with differential showed an elevated WBC count with left shift, and the erythrocyte sedimentation rate and C-reactive protein levels were elevated. Because she had not abused alcohol or other illicit substances in the past, and these were not accessible to her recently, substance abuse or dependence was not considered a likely cause of Ms. A’s psychotic symptoms. Similarly, depression may be a risk factor for developing dementia or be a prodrome of dementia (2) . All content was developed in collaboration with faculty who are paid consultants of Acadia. Auditory hallucinations mean the patient is hearing voices that are not there. There was the possibility that at this juncture any remaining psychosis and behavioral disturbance may be due primarily to Alzheimer’s type dementia, in which case a cognitive enhancer might be helpful by potentially stabilizing both the cognitive and noncognitive aspects of the dementia. Ms. A had atrial fibrillation and was on two atrioventricular nodal blocking medications (digoxin and the beta-blocker metoprolol, which had been started after a trial with a calcium channel blocker had failed to treat the arrhythmia). Treatment with cognitive enhancers was considered. Recent studies have reported that in patients with psychosis related to dementia, both conventional and atypical antipsychotics are associated with a greater risk of death, cerebrovascular incidents, and cardiovascular events (6 , 12) . They are often of a paranoid nature, where patients believe that items are being stolen from them, that they are being abandoned, or that their spouse and children are being disloyal to them. Nonpharmacologic interventions include individual, group, couples, and family psychotherapies; behavioral and milieu management; occupational therapies; expressive therapies, such as music and art therapies; and case management. For those with Alzheimer’s type dementia, antipsychotics seem to be more effective for paranoia, anger, and aggression (5) . Figure 1. Thus, a psychotropic “drug holiday” was initiated.

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