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Differential Diagnosis of Psychotic
Symptoms in Patients With Dementia
Full abbreviations, accreditation, and disclosure i...
Differential Diagnosis of Psychotic
Symptoms in Patients With Dementia
Full abbreviations, accreditation, and disclosure i...
The DICE Approach: Nonpharmacologic
Management of DRP Symptoms1
Full abbreviations, accreditation, and disclosure informat...
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Exploring Current Guidelines and Emerging Therapeutic Strategies for the Treatment of Dementia-Related Psychosis

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Marwan Sabbagh, MD, prepared useful practice aids pertaining to dementia-related psychosis for this CME activity titled "Exploring Current Guidelines and Emerging Therapeutic Strategies for the Treatment of Dementia-Related Psychosis." For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/2BlV6Ku. CME credit will be available until September 14, 2021.

Veröffentlicht in: Gesundheit & Medizin
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Exploring Current Guidelines and Emerging Therapeutic Strategies for the Treatment of Dementia-Related Psychosis

  1. 1. Differential Diagnosis of Psychotic Symptoms in Patients With Dementia Full abbreviations, accreditation, and disclosure information available at PeerView.com/QCV40 How does psychosis present in patients with dementia?1-3 What alternative etiologies need to be ruled out?4 • Psychotic symptoms include delusions and hallucinations and are categorized in a large constellation of symptoms referred to as behavioral and psychological symptoms of dementia (BPSD) • Delusions: fixed false beliefs that are maintained steadfastly, even in the face of contradictory evidence –– In dementia patients, delusions often have a persecutory or paranoid theme • Hallucinations: sensory perceptions occurring in the absence of corresponding external stimuli –– Can occur in any modality (visual, auditory, or somatic); visual hallucinations are more common in dementia patients than in patients with schizophrenia • Sensory deprivation: Poor vision can cause visual hallucinations; poor hearing can cause auditory hallucinations • Medical comorbidities: delirium; urinary tract infection; pain; tumors; strokes; hypoglycemia or hyperglycemia; hypothyroidism or hyperthyroidism; sodium or potassium imbalances; Cushing syndrome; Parkinson's disease; B12 deficiency; sleep deprivation; AIDS; seizure disorders (eg, temporal lobe epilepsy) • Medication toxicities: steroids; benzodiazepines; anti-parkinsonian agents; anticholinergics; alcohol, including alcohol withdrawal; stimulants; heart medicines; opioid analgesics • Psychiatric comorbidities: bipolar disorder; depression; late-onset schizophrenia (can be confused with frontal temporal dementia); late-life delusional disorder
  2. 2. Differential Diagnosis of Psychotic Symptoms in Patients With Dementia Full abbreviations, accreditation, and disclosure information available at PeerView.com/QCV40 1. Cummings JL et al. Neurology. 1994;44:2308-2314. 2. Rockwood K et al. Int J Geriatr Psychiatry. 2015;30:357-367. 3. Kales HC et al. BMJ. 2015;350:h369. 4. https://qioprogram.org/sites/default/files/ AGS_Guidelines_for_Telligen.pdf. 5. Meeks T et al. FOCUS. 2009;7:3-16. 6. https://geriatricscareonline.org/FullText/B023/B023_VOL001_PART001_SEC004_CH035#CH035_SEC003. 7. Kaufer D et al. J Neuropsychiatry Clin Neurosci. 2000;12:233-239. What is involved in the diagnostic workup?5,6 Neuropsychiatric Inventory-Questionnaire (NPI-Q)7 • Medical history: Ask the caregiver to provide this information –– Determine time course of psychiatric symptoms –– Review all current medications the patient is taking, and determine whether medication is being taken correctly • Laboratory testing: electrolyte levels, thyroid, liver, renal function, B12 levels, urinalysis, complete blood count, lipid panel, fasting glucose, rapid plasma (to assess prescription drug levels) –– Can test for syphilis, HIV, or substances of abuse as needed • Imaging: With magnetic resonance imaging (MRI) or computed tomography (CT) scan, assess for stroke or mass lesions or normal pressure hydrocephalus –– Electrocardiogram (ECG): Check for heart damage, since psychotropic agents can affect the heart conduction • Psychiatric symptoms: Screen with a validated measure such as the Neuropsychiatric Inventory-Questionnaire • Developed and cross-validated with standard NPI to provide a very brief assessment of 12 categories of neuropsychiatric symptomatology • Assessment of the type, frequency, severity, pattern, and timing of psychotic symptoms over the past month • Also provides a symptom severity rating and caregiver distress rating for each symptom reported, as well as total severity and distress scores reflecting sum of each domain score • Can be used in routine clinical settings • NPI-Q is filled out by the informant/caregiver, perhaps in the waiting room before the appointment • Takes about 5 or 10 minutes to complete and can be reviewed by the clinician very quickly in the course of the interview • NPI-Q can be found at http://npitest.net/
  3. 3. The DICE Approach: Nonpharmacologic Management of DRP Symptoms1 Full abbreviations, accreditation, and disclosure information available at PeerView.com/QCV40 1. Kales HC et al. J Am Geriatr Soc. 2014;62:762-769. • Caregiver describes problematic behavior –– Context (who, what, when, and where) –– Social and physical environment –– Patient perspective –– Degree of distress to patient and caregiver • Provider, caregiver, and team collaborate to create and implement treatment plan –– Respond to physical problems –– Strategize behavioral interventions ØØ Providing caregiver education and support ØØ Enhancing communication with the patient ØØ Creating meaningful activities for the patient ØØ Simplifying tasks ØØ Ensuring that the environment is safe ØØ Increasing or decreasing stimulation in the environment • Provider evaluates whether “CREATE” interventions have been implemented by caregiver and are safe and effective • Provider investigates possible causes of problem behavior –– Patient ØØ Medication side effects ØØ Pain ØØ Functional limitations ØØ Medical conditions ØØ Psychiatric comorbidity ØØ Severity of cognitive impairment, executive dysfunction ØØ Poor sleep hygiene ØØ Sensory changes ØØ Fear, sense of loss of control, boredom –– Caregiver effects/expectations –– Social and physical environment –– Cultural factors Describe Investigate Create Evaluate Considerationofpsychotropicuse(acuity/safety)

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