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.

1. Differential Diagnosis of Psychotic
Symptoms in Patients With Dementia
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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. Differential Diagnosis of Psychotic
Symptoms in Patients With Dementia
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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. The DICE Approach: Nonpharmacologic
Management of DRP Symptoms1
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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)