Cholinesterase Inhibitors are the preferred medication for treating visual hallucinations in LBD, but if they don’t work, antipsychotic drugs may be necessary. For Lewy Body psychosis, clozapine is the most effective option, although quetiapine is also a viable alternative. In Parkinson’s disease dementia with psychosis, a review by the Movement Disorder Society found that clozapine was effective and had an acceptable risk with proper monitoring. Quetiapine was considered investigational due to a lack of supporting evidence, while olanzapine was deemed unlikely to be effective and had an unacceptable risk due to its demonstrated worsening of motor function.

Management of Non-Cognitive Symptoms in Dementia

Non-cognitive symptoms of dementia can include agitation, aggression, distress, psychosis, depression, anxiety, sleep problems, wandering, hoarding, sexual disinhibition, apathy, and shouting. Non-pharmacological measures, such as music therapy, should be considered before prescribing medication. Pain may cause agitation, so a trial of analgesics is recommended. Antipsychotics, such as risperidone, olanzapine, and aripiprazole, may be used for severe distress of serious risk to others, but their use is controversial due to issues of tolerability and an association with increased mortality. Cognitive enhancers, such as AChE-Is and memantine, may have a modest benefit on BPSD, but their effects may take 3-6 months to take effect. Benzodiazepines should be avoided except in emergencies, and antidepressants, such as citalopram and trazodone, may have mixed evidence for BPSD. Mood stabilizers, such as valproate and carbamazepine, have limited evidence to support their use. Sedating antihistamines, such as promethazine, may cause cognitive impairment and should only be used short-term. Melatonin has limited evidence to support its use but is safe to use and may be justified in some cases where benefits are seen. For Lewy Body dementia, clozapine is favored over risperidone, and quetiapine may be a reasonable choice if clozapine is not appropriate. Overall, medication should only be used when non-pharmacological measures are ineffective, and the need is balanced with the increased risk of adverse effects.

Dementia: Types and Clinical Characteristics

Dementia is a progressive impairment of cognitive functions occurring in clear consciousness. There are over 100 different causes of dementia, and a detailed knowledge is required for the more common types. The following are some of the subtypes of dementia, along with their early features, neuropathology, and proportion:

– Alzheimer’s disease: Impaired memory, apathy, and depression; gradual onset; cortical amyloid plaques and neurofibrillary tangles; 50-75% proportion.
– Vascular dementia: Similar to AD, but memory less affected, and mood fluctuations more prominent; physical frailty; stepwise onset; cerebrovascular disease; single infarcts in critical regions, of more diffuse multi-infarct disease; 20-30% proportion.
– Frontotemporal dementia: Personality changes, mood changes, disinhibition, language difficulties; no single pathology – damage limited to frontal and temporal lobes; 5-10% proportion.
– Dementia with Lewy Bodies: Marked fluctuation in cognitive ability, visual hallucinations, Parkinsonism (tremor and rigidity); cortical Lewy bodies (alpha-synuclein); <5% proportion. Other types of dementia include Pick’s disease, Huntington’s disease, pseudodementia, and progressive supranuclear palsy. Each subtype has its own unique clinical characteristics and neuropathology. It is important to accurately diagnose the type of dementia in order to provide appropriate treatment and care.

Despite the limited data available, the college remains interested in the topic. According to Harwood’s (2001) study, anankastic personality disorder appears to be more common among older individuals who die by suicide. The study was both descriptive and case-controlled. It was published in the International Journal of Geriatric Psychiatry and can be found in Volume 16, Issue 2, pages 155-165.

Suicide in the Elderly

Self-harm in older individuals should be approached with caution as approximately 20% of completed suicides occur in those over the age of 65. Studies have consistently found that more than half of those who commit suicide after the age of 65 are suffering from a depressive disorder at the time of death. Personality traits also appear to play a role, with an association between suicide in older individuals and anankastic (obsessional) and anxious personality traits observed in one study. Dissocial of borderline disorders are more commonly found in younger suicide victims. It is important to be aware of these factors when assessing and treating suicidal behavior in the elderly.

According to the National Institute for Health and Care Excellence (NICE) guideline for managing Dementia (CG42), if Lewy body dementia is suspected based on symptoms such as falls, fluctuating consciousness, visual hallucinations, and parkinsonism, SPECT scanning should be used to detect dopaminergic deterioration. Additionally, CT/MRI should be used to distinguish between Alzheimer’s dementia and vascular dementia.

Huntington’s disease is more likely to cause a lack of initiative than a depressed mood.

Psychiatric and Behavioural Symptoms of Huntington’s Disease

Huntington’s disease is a condition that affects individuals with a triad of symptoms, including motor, cognitive, and psychiatric symptoms. While the symptoms typically begin in the third and fourth decades of life, individuals with a high number of CAG repeats may experience symptoms before the age of 20, known as juvenile Huntington’s disease.

The psychiatric symptoms of Huntington’s disease can include depression, apathy, dementia, psychosis, anxiety, mania, sexual dysfunction, and even suicide. These symptoms can significantly impact an individual’s quality of life and require appropriate treatment. Advances in psychiatric treatment have been made to address these symptoms and improve the overall well-being of individuals with Huntington’s disease.

Psychiatric and Behavioural Symptoms of Huntington’s Disease

Huntington’s disease is a condition that affects individuals with a triad of symptoms, including motor, cognitive, and psychiatric symptoms. While the symptoms typically begin in the third and fourth decades of life, individuals with a high number of CAG repeats may experience symptoms before the age of 20, known as juvenile Huntington’s disease.

The psychiatric symptoms of Huntington’s disease can include depression, apathy, dementia, psychosis, anxiety, mania, sexual dysfunction, and even suicide. These symptoms can significantly impact an individual’s quality of life and require appropriate treatment. Advances in psychiatric treatment have been made to address these symptoms and improve the overall well-being of individuals with Huntington’s disease.

In Parkinson’s disease, only clozapine and quetiapine are appropriate antipsychotic medications, and if one is not well-tolerated, the other may be considered.

Parkinson’s Disease: Presentation, Aetiology, Medical Treatment, and Psychiatric Aspects

Parkinson’s disease is a degenerative disease of the brain that is characterised by motor symptoms such as rigidity, bradykinesia, and tremor. It has a long prodromal phase and early symptoms generally present asymmetrically. The tremor associated with Parkinson’s disease is classically described as ‘pill rolling’. The principle abnormality is the degeneration of dopaminergic neurons in the pars compacta of the substantia nigra, which leads to an accumulation of alpha-synuclein in these abnormal dopaminergic cells. The majority of cases of Parkinson’s disease are idiopathic, but single gene mutations occur in a minority of cases. Pesticide, herbicide, and heavy metal exposures are linked to an increased risk of Parkinson’s disease in some epidemiologic studies, whereas smoking and caffeine use are associated with decreased risks.

Treatment for Parkinson’s disease predominantly focuses on symptomatic relief with drugs aiming to either restore the level of dopamine in the striatum of to act on striatal postsynaptic dopamine receptors. However, as dopamine is not the only neurotransmitter involved in Parkinson’s disease, many other drugs are also being used to target specific symptoms, such as depression of dementia. Psychiatric symptoms are common in Parkinson’s disease and range from mild to severe. Factors associated with severe symptoms include age, sleep disturbance, dementia, and disease severity. Hallucinations are common in Parkinson’s disease and tend to be visual but can be auditory of tactile. In the majority of patients, psychotic symptoms are thought to be secondary to dopaminergic medication rather than due to the Parkinson’s disease itself. Anticholinergics and dopamine agonists seem to be associated with a higher risk of inducing psychosis than levodopa of catechol-O-methyltransferase inhibitors. Medications used for psychotic symptoms may worsen movement problems. Risperidone and the typicals should be avoided completely. Low dose quetiapine is the best tolerated. Clozapine is the most effective antipsychotic drug for treating psychosis in Parkinson’s disease but its use in clinical practice is limited by the need for monitoring and the additional physical risks.

Risperidone is the sole atypical antipsychotic approved for managing short-term aggression in dementia patients who have not responded to behavioral interventions. However, antipsychotics carry risks of adverse effects, including heightened confusion and falls. In elderly individuals, traditional antipsychotics may cause extrapyramidal side effects and QTc prolongation.

Although the distinction between cortical and subcortical dementia is now considered arbitrary and there is limited evidence to support it, the college continues to include it as a question.

Distinguishing Cortical and Subcortical Dementia: A Contested Area

Attempts have been made to differentiate between cortical and subcortical dementia based on clinical presentation, but this remains a contested area. Some argue that the distinction is not possible. Cortical dementia is characterized by impaired memory, visuospatial ability, executive function, and language. Examples of cortical dementias include Alzheimer’s disease, Pick’s disease, and Creutzfeldt-Jakob disease. On the other hand, subcortical dementia is characterized by general slowing of mental processes, personality changes, mood disorders, and abnormal movements. Examples of subcortical dementias include Binswanger’s disease, dementia associated with Huntington’s disease, AIDS, Parkinson’s disease, Wilson’s disease, and progressive supranuclear palsy. Despite ongoing debate, questions on this topic may appear in exams.

Delirium (also known as acute confusional state) is a condition characterized by a sudden decline in consciousness and cognition, with a particular impairment in attention. It often involves perceptual disturbances, abnormal psychomotor activity, and sleep-wake cycle impairment. Delirium typically develops over a few days and has a fluctuating course. The causes of delirium are varied, ranging from metabolic disturbances to medications. It is important to differentiate delirium from dementia, as delirium has a brief onset, early disorientation, clouding of consciousness, fluctuating course, and early psychomotor changes. Delirium can be classified into three subtypes: hypoactive, hyperactive, and mixed. Patients with hyperactive delirium demonstrate restlessness, agitation, and hyper vigilance, while those with hypoactive delirium present with lethargy and sedation. Mixed delirium demonstrates both hyperactive and hypoactive features. The hypoactive form is most common in elderly patients and is often misdiagnosed as depression of dementia.