1/20. Initiating and monitoring cholinesterase inhibitor treatment for Alzheimer's disease.The availability of acetylcholinesterase inhibitors for the treatment of Alzheimer's disease raises a number of clinical and ethical questions. Many of the guidelines published in an attempt to tackle these questions lack either clinical or scientific validity. Against this background a model is proposed whereby specialist monitoring using formal tests is neither appropriate nor necessary to determine whether an individual patient should continue or stop treatment. Instead the primary care physician should refer potentially suitable patients for specialist assessment to confirm the diagnosis/He/she should then initiate, monitor, and discontinue treatment based on the establishment of realistic treatment goals agreed with the patient/carer at the outset.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/20. physicians' decision-making in incompetent elderly patients: a comparative study between austria, germany (East, West), and sweden.In order to investigate to what extent various determinants in the decision-making process for the treatment of severely ill incompetent patients are influenced by cultural and sociopolitical factors, 540 physicians in austria, germany (East and West), and sweden, countries representing different healthcare systems, were surveyed using a self-administered questionnaire. It provided three case vignettes with different levels of information about the patient's treatment wishes in case of incompetence in a life-threatening situation. We found a general trend to a lower level of treatment in line with the patient's wishes when the information provided was more detailed. Remarkably, a substantial number of doctors did not comply with the patient's wishes. Ethical concerns and patient's wishes appeared as the most important factors whereas religious beliefs of the physician and hospital costs scored lowest. Because of the variability of treatment decisions and the importance of various factors determining the decision-making, an advance directive may be a feasible way of reducing the number of conflicts in critical situations. We recommend that ethical issues of clinical practice should be emphasized in the medical curriculum and in the training of physicians.- - - - - - - - - - ranking = 3keywords = physician (Clic here for more details about this article) |
3/20. Lewy body dementia: case report and discussion.BACKGROUND: Lewy body dementia is a common but frequently underdiagnosed cause of dementia often mistaken for the more familiar entity of alzheimer disease. Clinically the distinction is important, because it can have profound implications for management. methods: The medical literature was searched using the keywords "lewy bodies," "Lewy body dementia," "Alzheimer dementia," and "parkinsonian disorders." A case of Lewy body dementia is described. RESULTS: An elderly man had long-standing diagnoses of alzheimer disease and parkinson disease. After he was evaluated thoroughly, the diagnosis was revised to Lewy body dementia, leading to changes in treatment that were associated with dramatic improvement in the patient's mental status. Evidence from the literature suggests that Lewy body dementia can be diagnosed in primary care settings based on clinical criteria. The physician should be alert to this diagnosis, and special attention should be paid to dementia patients who exhibit parkinsonism, hallucinations, fluctuating cognition, or prominent visuosperceptual deficits. CONCLUSIONS: The diagnosis of Lewy body dementia has important implications. It is associated with a high incidence of neuroleptic sensitivity, necessitating great caution in the use of these common antipsychotic agents. Early studies indicate cholinesterase inhibitors can be beneficial for treating the hallucinations and behavior disturbances that afflict these patients and might also improve cognition.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/20. Cognitive screening in the primary care setting. The role of physicians at the first point of entry.There are many reasons why it is important to conduct the cognitive assessment and arrive at a preliminary diagnosis within the primary care setting. In addition to starting the patient on anti-cholinesterase medications, the physician must discuss with the family (and often the patient) issues related to financial matters and self-care. Alzheimer's patients who live alone may be targets for financial and personal exploitation, and are at risk for self-neglect. Community support or provision might be needed to assist with medication compliance, provide nutritional services by shopping for prepared foods or through meals on Wheels, housekeeping to maintain cleanliness, adult day services to provide social and recreational activities, live-in companions, and assistance with other instrumental activities of daily living. Sometimes more structured or institutional living is necessary. Generally, the primary care practice is not set up to coordinate these additional services, as well as to provide ongoing care. We will discuss potential solutions to providing ongoing care in next month's column.- - - - - - - - - - ranking = 5keywords = physician (Clic here for more details about this article) |
5/20. health professionals' views on standards for decision-making capacity regarding refusal of medical treatment in mild Alzheimer's disease.This study was designed to determine which elements professionals consider important for evaluation of decision-making capacity. Survey with a vignette case report of an individual with mild dementia was mailed to four groups of individuals: 1. members of the Academy of psychosomatic medicine, 2. chairs of veterans Affairs (VA) ethics advisory committees (EACs), 3. randomly selected geriatricians who were members of the Gerontological Society of America (GSA), and 4. randomly selected psychologists who were members of the GSA. Two hundred thirty-seven psychiatrists, 95 VA EAC chairs, 103 geriatricians, and 46 psychologists responded to this survey. The majority of the respondents endorsed all five basic elements as necessary for determination of decision-making capacity in the presented vignette, but only a minority of respondents endorsed all five basic elements, and a small proportion of respondents endorsed only one or two elements. The results indicate that physicians do not use uniform standards for assessment of decision-making capacity.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/20. Orally disintegrating olanzapine for the treatment of psychotic and behavioral disturbances associated with dementia.Orally disintegrating olanzapine is a recently marketed form of olanzapine that dissolves rapidly on contact with saliva. We describe six demented patients resistant to treatment with common oral antipsychotic medications who were successfully treated with the formulation. The importance of these case reports is to make physicians aware that orally disintegrating olanzapine may be useful for the management of psychobehavioral disturbances in demented patients who resist or have difficulty taking standard oral medications.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/20. Steroid dementia: an overlooked diagnosis?The authors studied a 72-year-old man with polymyalgia rheumatica who, after taking 100 mg of prednisone for 3 months, developed a psychosis followed by dementia. It was initially considered that the dementia was a separate neurodegenerative condition, probably of Alzheimer type, but when steroids were discontinued, he rapidly returned to his previous level of functioning. Reviewing the literature regarding the effects of steroids on cerebral function, the authors found that such cases of "reversible dementia" are not uncommon, although rarely given the emphasis they deserve. The authors believe, given the extensive use of steroids in medical practice, that physicians should be more aware of this important cause of reversible dementia.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/20. Spongiform encephalopathies: the physician's responsibility.The spongiform encephalopathies encompass several diseases affecting humans and animals. In the united states, the most common of these disorders in humans is Creutzfeldt-Jakob disease. The most frequent manifestations include dementia, pyramidal tract signs, and extrapyramidal movement disorder. Several clinically distinct syndromes can be identified. Often the diagnosis is confused with other forms of dementia, and the only definitive method for establishing the diagnosis is autopsy evaluation of brain tissue. Unfortunately, since the recognition of the infectious etiology of Creutzfeldt-Jakob disease, fear has often unreasonably interfered with clinical care and autopsy evaluation of affected patients. In actuality, because of the low and restricted infectivity of the responsible agent, affected individuals present minimal risks to clinical caretakers, and handling of patient specimens is not dangerous if appropriate precautions are taken. These precautions are well established, and physicians and other health care workers should not refuse care of appropriate evaluation (including autopsy) to individuals with suspected Creutzfeldt-Jakob disease.- - - - - - - - - - ranking = 5keywords = physician (Clic here for more details about this article) |
9/20. Recognition and treatment of depression in Alzheimer's disease.Although there is no generally effective treatment for Alzheimer's disease, some common psychiatric symptoms associated with the disease, including depression, may respond to pharmacological intervention. Recognition of the depression requires a high index of suspicion from the primary care physician and caregivers and a history from family members or other caregivers. Several groups of medications, including tricyclic antidepressants, monoamine oxidase inhibitors, and psychostimulants, have been used for treatment of depression in dementia patients. Generally, Alzheimer's patients require lower dosages of medication and longer drug treatment trials than younger patients treated for depression.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/20. chelation therapy. Unproved modality in the treatment of Alzheimer-type dementia.Despite a dramatic increase in the understanding of the neuropathologic and neurochemical alterations accompanying Alzheimer's disease, by far the largest cause of progressive and incapacitating cognitive dysfunction in the elderly, physicians have as yet no pharmacologic agent that can be prescribed safely either to arrest or reverse this decline. This lack of effective therapeutic agents is contributing to the use by an increasing number of health professionals, including physicians and concerned families, of unproved, costly, and potentially dangerous modalities, such as chelation therapy. The purpose of this paper is to describe some individuals with Alzheimer-type dementia who have undergone chelation therapy.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
| | Next -> |