1/24. Debate: what constitutes 'terminality' and how does it relate to a living will?A moribund and debilitated patient arrives in an emergency department and is placed on life support systems. Subsequently it is determined that she has a 'living will' proscribing aggressive measures should her condition be judged 'terminal' by her physicians. But, as our round table of authorities reveal, the concept of 'terminal' means different things to different people. The patient's surrogates are unable to agree on whether she would desire continuation of mechanical ventilation if there was a real chance of improvement or if she would want to have her living will enforced as soon it's terms were revealed. The problem of the potential ambiguity of a living will is explored.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/24. Alternative medicine. Achieving balance between herbal remedies and medical therapy.The case patient was taking multiple herbal preparations as well as the prescription hypnotic zolpidem. The combination was probably increasing the patient's confusion, agitation, and aggression. The treatment team reached a compromise with the daughter after providing her with education and support. They continued the wheat germ oil and a multivitamin supplement, which appeared safe, even if of limited value. The patient continued taking valproate, 125 mg bid, which reduced her physical aggression and improved resistance to care. All other herbal remedies and zolpidem were discontinued. Balancing traditional therapies with requests for herbal remedies is a common challenge for physicians. The most successful intervention occurs when doctors familiarize themselves with herbal preparations and educate patients and families about the treatments.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/24. Behavioral and psychological symptoms of dementia. Assisting the caregiver and managing the patient.Behavioral and psychological symptoms of dementia cause many problems for patients and caregivers. Fortunately, physician intervention and pharmacologic and nonpharmacologic approaches to managing the patient provide hope for successful treatment. New antipsychotic agents and pharmacologic treatments are in development and may provide greater benefits to patients and their caregivers.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
4/24. 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) |
5/24. 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) |
6/24. Behavioural disturbances following Japanese B encephalitis.Clinically, Japanese B encephalitis (JBE) is often overlooked as its occurrence in Western countries is rare. However, its neurological, cognitive and psychiatric sequelae constitute a major public health problem in the far east where JBE is endemic. European and American subjects may however experience the JBE when returning from a far east journey. In such cases, misdiagnosis is frequent because of the unawareness of psychiatrists and physicians. The present review, therefore, documents the behavioural and cognitive sequelae of JBE. This reactivates the debate concerning the vaccination against the virus all the more that the literature enlightens the importance of the vaccination for those who undertake frequent and extensive tourist excursions to the Orient but still discusses it for occasional travellers. Following is a case-report of a young western European post-graduate student who has contracted JBE by experiencing an acute febrile delirium during an unusual short stay in South East asia. Pyramidal syndrome, Parkinsonism and amnesia were the prominent acute deficits. Whereas these faded in great part during convalescence, emotional and behavioural instability associated with affective involvement, obsessive-compulsive symptoms and cognitive impairments appeared. A partial recovery was however obtained with neuroleptics, lithium and following electro-convulsive therapy. Organic personality syndrome was persistent and thereafter constituted the main sequelae syndrome. Hypersomnia and several enuretic episodes persisted.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/24. Infusion technique can be used to distinguish between dysfunction of a hydrocephalus shunt system and a progressive dementia.In a deteriorating shunted patient with hydrocephalus, an investigation of shunt function is often performed to distinguish a dysfunctioning shunt from an aggravated condition of the disease. The paper illustrates how a lumbar cerebrospinal fluid (CSF) infusion method can be used to evaluate post-operative deterioration in a shunted patient in order to give the physician valuable support in the shunt revision decision. A 77-year-old man with hydrocephalus was treated operatively by the insertion of a CSF shunt. Owing to shunt failure, the shunt was revised twice during a 5 year period. Using a computerised infusion technique method, with two needles placed in the lumbar subarachnoid space, the CSF dynamic system was determined pre- and post-operatively with the functioning as well as the dysfunctioning shunts. The data were verified with a bench-test of the extirpated CSF shunt. There was a significant difference in conductance G between CSF systems with an open shunt and CSF systems with no shunt or an occluded shunt (deltaG= 38 mm3 s(-1) kPa(-1), p = 0.014, n= 7, ANOVA). CSF dynamics investigations, with and without a shunt, can give valuable clinical support in the management of a deteriorating hydrocephalus patient. With further development of the lumbar infusion method moving towards easy-to-use equipment, there is potential for widespread clinical use.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/24. 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) |
9/24. Three clinical problems: weird thyroid function tests, difficult gout, and dementia.Speakers at the course were given vignettes describing one or more clinical scenarios on which to base their talks, selected because they represent common but challenging problems likely to be encountered by any physician practising in general internal medicine. Three of the subjects covered--weird thyroid function tests, difficult gout, and dementia--are presented here.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
10/24. Approach to managing behavioural disturbances in dementia.OBJECTIVE: To review practical evidence-based treatment of behavioural symptoms in dementia. SOURCES OF INFORMATION medline: Was searched from January 1966 to December 2004 and PsycINFO from January 1967 to December 2004 using the key words "BPSD" (behavioural and psychological symptoms of dementia) and "behavioral disturbances dementia." I also reviewed the bibliographies of recent review papers and original articles. MAIN MESSAGE: family physicians who manage hospital inpatients and care for people in nursing homes are asked to prescribe medications for demented patients. This review discusses alternatives to drugs, indications for appropriate use of drugs, frequently encountered side effects of drugs, and considerations for those with neuroleptic sensitivity. I suggest an approach that employs a combination of behavioural, environmental, and pharmacologic interventions to address disruptive behaviour in patients with dementia. CONCLUSION: Optimal treatment of behavioural disturbances in patients with dementia involves nonpharmacologic approaches and using medications with demonstrated efficacy. Pharmacologic treatment should target only those symptoms or behaviours that respond to medication. This approach minimizes unnecessary medication use and reduces adverse outcomes.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
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