Dementia in the era of COVID-19. Some considerations and ethical issues.

Living with dementia at any time brings everyday challenges for the patient and those around him/her. The Covid-19 pandemic is making daily life harder. We aim to describe the problems of people with dementia during the time of such a pandemic and address the issue of their access to intensive care units. A systematic literature search (Cochrane Library (advanced search), and PubMed) was performed (for items up to 19 August 2020) using the following terms: 'COVID-19', 'dementia', and 'intensive care unit'. Studies were independently evaluated and selected for potential analysis. Five of 35 articles initially selected met the inclusion criteria. An additional Google Scholar search identified some striking statements from relevant authorities or scientists about the difficulty of living with dementia in the era of COVID-19, and were also reported. To summarize, dementia-related behaviours, increased age, and comorbid health conditions may increase the risk of contracting the virus. People with dementia in their own homes may already feel isolated, and additional rules for self-isolation may make this worse. As COVID-19 is spreading worldwide, governments and health authorities should devise better criteria for accessing intensive care units and allocating ventilators. If someone is given preference for medical care, it should be because that person has a better short-term prognosis, not simply because that person is younger than someone else.

'I am dead': Cotard syndrome and dementia.

Background: Cotard syndrome is a rare condition whose main feature is a nihilistic delusion ranging from the denial of body parts to that of the existence of one's own life or even the entire universe. Objectives: The aim of this article is to review the nosological significance of Cotard syndrome and to explore the disorder among patients with dementia. Methods: Medline and Google Scholar searches were conducted for relevant articles, chapters and books published before 2018. Search terms used included Cotard delusion, Cotard syndrome and dementia, nihilistic delusion. Publications found through this indexed search were reviewed for further relevant references. Results and conclusion: In this narrative review we emphasise the fact that cases of Cotard syndrome involving patients with dementia are reported quite infrequently. Published studies are limited to very short series or isolated cases. Clinicians are obliged to treat the disorder. They should be alert to the potential high risk inherent in this condition. Keypoints Cotard syndrome is a rare condition characterised by nihilistic delusions that may range from negation of existence of parts of the body to delusion of being dead. The prevalence and incidence of this rare syndrome are not known. Since Cotard's syndrome is conceptualised as part of an underlying disorder, several psychiatric and somatic diseases have been associated with the syndrome. The syndrome may occur in patients suffering from dementia.

Bipolar Disorder and Cognitive Dysfunction: A Complex Link.

The aim of this article was to describe the current evidence regarding phenomenon of cognitive functioning and dementia in bipolar disorder (BD). Cochrane Library and PubMed searches were conducted for relevant articles, chapters, and books published before 2016. Search terms used included "bipolar disorder," "cognitive dysfunction," and "dementia." At the end of the selection process, 159 studies were included in our qualitative synthesis. As result, cognitive impairments in BD have been previously considered as infrequent and limited to the affective episodes. Nowadays, there is evidence of stable and lasting cognitive dysfunctions in all phases of BD, including remission phase, particularly in the following domains: attention, memory, and executive functions. The cause of cognitive impairment in BD raises the question if it subtends a neurodevelopmental or a neurodegenerative process. Impaired cognitive functioning associated with BD may contribute significantly to functional disability, in addition to the distorted affective component usually emphasized.

Personality and destiny. Francesco Borromini: portrait of a tormented soul.

Francesco Borromini, one of the great geniuses of Baroque architecture, was tormented and solitary, and was increasingly frustrated by the fame and success of his rival, Gian Lorenzo Bernini. Borromini was an unhappy man, constantly dogged by disaster, quarrelling even with his best patrons and closest friends. In the culmination of one of the fits of depression that overcame the architect more and more frequently as his life progressed, Borromini literally fell on his own sword; he lingered in excruciating pain for 24 hours before dying. Largely forgotten, his architecture has again been recognized since the twentieth century as the creation of genius. We try to describe the personality and suicide of this pessimist giant of architecture.

Armed and Aging: Dementia and Firearms Do Not Mix !

The possibility that persons with dementia possess firearms is cause for concern, but only a limited number of research studies have been conducted on such a topic, usually in the form of case reports. Reducing the occurrence of the firearm-related violence requires effectively identifying dangerous individuals and keeping firearms out of their hands. The health care professionals, i.e. the social workers and the physicians, need to work together and to produce a suitable evaluation of patients with dementia to prevent firearm-related injuries and serious and irreparable damage to persons.

Personality and dementia.

Personality describes persistent human behavioral responses to broad classes of environmental stimuli. Change in personality may be an early sign of dementia. Our goal was to review scientific literature on the association between personality and dementia. Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published since 1980. Search terms used included personality, dementia, Alzheimer's disease, frontotemporal dementia, dementia with Lewy bodies. People with dementia commonly exhibit changes in personality that sometimes precede the other early clinical manifestations of the condition, such as cognitive impairment. Premorbid personality might be a determining factor so that caricature or exaggeration of original personality emerges as dementia progresses. Although it is generally accepted that these personality changes reflect the impact of progressive brain damage, there are several possible patterns of personality alterations with dementia. Early identification of personality modifications might assist with the timely diagnosis of dementia.

Categorising a problem: alcohol and dementia.

Alcoholism is a chronic relapsing disorder that can include extended periods of abstinence followed by relapse to heavy drinking. Decades of evidence have clearly shown that long-term, chronic ethanol exposure produces brain damage in humans. The article aims to review the relationship between alcohol use and dementia. Medline and Google Scholar searches were conducted for relevant articles, chapters and books published until 2019. Search terms used included alcohol consumption, alcohol-related dementia, alcohol use disorders, chronic alcoholism, dementia. Publications found through this indexed search were reviewed for further relevant references. Alcohol acts on the central nervous system via both direct and indirect effects, frequently a combination of the two. There is consensus that alcohol contributes to the acquisition of cognitive deficits in late life. However, there are doubts regarding the aetiopathogenesis, nosological status and prevalence of alcohol-related dementia and still, there is much debate over how much alcohol consumption will lead to alcohol-related dementia.

Is that schizophrenia or frontotemporal dementia? Supporting clinicians in making the right diagnosis.

Schizophrenia (SCH) and frontotemporal dementia (FTD) are neurobehavioral syndromes characterized by a profound alteration in personal and social conduct. Differential diagnosis between SCH and FTD remains a challenge. In this short narrative review, we summarize evidences regarding similarities and differences between these disorders to support clinicians in making the right diagnosis. Reports of FTD misdiagnosed as schizophrenia or schizophrenia-like psychosis are frequently reported in the literature. The behavioural variant of FTD (bvFTD) along with familial FTD characterized by delusions and hallucinations represent the medical conditions that best illustrate overlaps between psychiatry and neurology. Neuropsychological patterns of core deficits and anatomical and physiological brain alterations primarily concur in differencing such disorders while additional research on genetic alterations and their reflection on clinical phenotypes should be implemented in the near future. In some cases, a correct diagnosis should be made within an interdisciplinary clinical setting by complementary competences and follow-up visits to evaluate pathology evolution.

A complication of coronavirus disease 2019: delirium.

COVID-19 is predominantly a respiratory disease. However, some cases exhibit other features including Central Nervous System symptoms. In the older adult, COVID-19 may present with atypical symptoms, including delirium and its complications. The objective of this study is to describe the relationship between the new type of coronavirus infection and delirium. Systematic research (Cochrane Library and PubMed) was carried out (only upper time limit: April 2020). Publications found through this indexed search were reviewed and manually screened to identify relevant studies. Search terms used included "COVID-19, Delirium, Dementia, Intensive Care Unit". We manually added articles identified through other sources (i.e., key journals). Older people are at the greatest risk from COVID-19. If infected, they may present delirium. Moreover, it is not exclusive to older people. Delirium is not inevitable; rather, it is preventable. Delirium prevention programs are even more crucial in the era of COVID-19 and cannot be allowed to wither despite the challenges of integrating delirium prevention with COVID-19 care. An acute change in condition, behaviour, or mental status should prompt a delirium screen. As regards the treatment, it is advisable to use non-pharmacological interventions first where possible. Medication may be needed for patients with agitation where there is intractable distress or high risk to self/others.

Euthanasia and other end of life in patients suffering from dementia.

Medicine aims to relieve patient suffering and cure illness. To relieve suffering is the heart of what doctors do. However, respect for individual autonomy and self-determination are fundamental principles in Western medical ethics and decision-making, often expressed as a desire for control over the timing and manner of death. Patients who become demented often formulate advance euthanasia and assisted suicide directives. Dealing with such request is quite complex because of the specific medical and conflicting ethical questions they raise. Some specific medical and ethical issues arise regarding these substantive requirements when evaluating the euthanasia request of a person suffering from dementia. In jurisdictions that allow euthanasia, the most fundamental prerequisite for a person to make autonomous decisions is capacity. Whether anyone with moderate or severe dementia, and even some with mild dementia, could be deemed to be competent by these criteria is debatable, but during the course of their disease people with dementia sooner or later lose their capacity to make self-determined decisions.

Uncommon and/or bizarre features of dementia: part IV.

It is well established that the clinical picture of dementias is not clinically homogeneous. For example, non-amnestic presentations of Alzheimer's disease have been referred to as a typical variant. Careful examination of clinical characteristics contributes to understanding the neurobiology of Alzheimer's disease and other dementias and may in turn enhance knowledge of the potential risk factors involved. This study aimed at describing uncommon or bizarre symptoms/syndromes observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published before 2019. Search terms used included dementia, déjà vu, zoophilia, pathological lying, and somatic symptom disorder. Publications found through this indexed search were reviewed for further relevant references. Uncommon/bizarre features of dementia were described as case reports and there were no systematic investigations.

Links Between Painting and Neurology: The Example of Dementia.

Art is a system of human communication arising from symbolic cognition, conveying ideas, experiences, and feelings. The goal of this review is to describe the link between painting and dementia. Individuals with neurodegenerative diseases inevitably experience cognitive dysfunction that has the potential to limit and impair the artist's ability to realize their creative and expressive intentions through painting. The strategy to advance our understanding of the neural bases for art is to map locations and nature of neural damage to changes onto artistic production.

Aging With Down Syndrome: The Dual Diagnosis: Alzheimer's Disease and Down Syndrome.

BACKGROUND: People with Down syndrome (DS) enjoy a longer life expectancy now than they ever have before and are therefore at greater risk of developing conditions associated with aging, including dementia. OBJECTIVES: To explore the phenomenon of dementia in DS. METHODS: Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published until 2017. Search terms included Alzheimer's disease, cognitive impairment, dementia, DS, and trisomy 21. Publications found through this indexed search were reviewed for further references. RESULTS AND CONCLUSIONS: Virtually, all subject aged 35 to 40 show key neuropathologic changes characteristic of Alzheimer's disease, but only a part of them show clinical signs of dementia, usually around the age of 50 years. Early signs of dementia in people with DS may be different from those experienced by the general population. Failure to recognize this can delay diagnosis and subsequent interventions.

Art is long, life is short. Francisco José de Goya y Lucientes (1746-1828), the suffering artist.

Francisco José de Goya y Lucientes is one of the major figures of European art. From royal portraits to bizarre, grotesque illustrations, his legacy demonstrates a tortured genius, generating some of the most compelling art ever produced. His story is also the story of Spain during one of the most tumultuous passages of its history. In the winter of 1792-93, Goya experienced a mysterious illness resulting in lifelong deafness. After that, his work became more negative, with thick, bold strokes of dark colour. Scholars have suggested various diagnoses on the basis of Master's symptoms, but the exact nature of the illness has never been identified.

Uncommon and/or bizarre features of dementia. Part II.

In the past decades, clinicians have recognized that dementia may appear as atypical or variant syndromes, as well as the typical form. This study aimed at describing uncommon or bizarre symptoms/syndromes observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published before 2017. Search terms used included delusional jealousy, delusion of pregnancy, dementia, erotomania, folie à deux, and lycanthropy. Publications found through this indexed search were reviewed for further relevant references. The uncommon symptoms/syndromes were described as case reports and there were no systematic investigations.

Uncommon and/or bizarre features of dementia: Part III.

Clinical neurologists have long recognized that dementia can present as atypical or variant syndromes/symptoms. This study aimed at describing uncommon or bizarre symptoms/syndromes observed in patients suffering from dementia. Medline and Google scholar searches were conducted for relevant articles, chapters, and books published before 2018. Search terms used included compulsion, dementia, extracampine hallucination, disordered gambling, humour, and obsession. Publications found through this indexed search were reviewed for further relevant references. The uncommon/bizarre feature of dementia was described as case reports and there were no systematic investigations.

A Contagious Disorder: Folie à Deux and Dementia.

BACKGROUND: Folie à deux is a clinical condition that was first described in 19th century. It is a psychotic disorder in which two closely associated individuals share a similar delusional system. OBJECTIVES: The aim of this article is to review the nosological significance of folie à deux and to explore the disorder among patients with dementia. METHODS: Medline and Google Scholar searches were conducted for relevant articles, chapters, and books published before 2017. Search terms used included dementia, folie à deux, induced delusional disorder, neurocognitive disorders, shared psychotic disorder. Publications found through this indexed search were reviewed for further relevant references. RESULTS AND CONCLUSION: Cases of Folie à deux involving patients with dementia are reported quite infrequently. Most of the studies on the topic consist in case reports. Clinicians are obliged to treat the disorder. They should be alert to the potential high risk inherent this psychotic syndrome.

Old and dangerous: Prison and dementia.

Older prisoners are the fastest growing group of prisoners in many countries. The purpose of this study is to explore the phenomenon of detention of persons suffering from dementia. Medline searches were conducted for relevant articles, chapters and books published until August 2016. Search terms included dementia, elderly, prison and criminal. Publications found through this indexed search were reviewed for further relevant references. As results, there is a lack of data about elderly with dementia in prisons. Given the rise in the average age, it is reasonable to hypothesize that the number of older prisoners is growing. Moreover, some elderly are imprisoned with a concomitant cognitive impairment or psychiatric disorder while others will develop such diseases once incarcerated. At the present time, legal and social systems seem unprepared to handle the phenomenon of dementia in prison. As proposal, health assessments for older first time offenders should become a practice inside the correctional facilities and include an evaluation for specific health issues, such as psychiatric comorbidity and cognitive impairment.

Delusion of pregnancy: an unusual symptom in the context of dementia.

BACKGROUND: Delusions can complicate practically all brain disorders. They may be dramatic and bizarre. An example is the so-called delusion of pregnancy. OBJECTIVE: To identify the characteristic of a psychotic symptom, the phenomenon of delusion of pregnancy, in the context of dementia. METHOD: MEDLINE and Google Scholar searches were conducted for relevant articles, chapters, and books published before 2014. Search terms used included delusion of pregnancy, uncommon presentation, behavioral and psychological symptoms, dementia, Alzheimer's disease, and frontotemporal dementia (FTD). Publications found through this indexed search were reviewed for further relevant references. We included case reports that highlight the relationship and overlap between dementia presenting as schizophrenia-like psychosis and schizophrenia. RESULTS: Literature on delusion of pregnancy in the course of dementia consists mostly of case reports and small samples of patients. CONCLUSION: Psychotic phenomena such as delusion of pregnancy may be a feature in some cases of dementia. If this bizarre features of dementia appears as early presentation of FTD whose usual onset is in the presenium, it may be mistaken for schizophrenia.

Treatment of depressive symptoms in patients with schizophrenia: a randomized, open-label, parallel-group, flexible-dose subgroup analysis of patients treated with extended-release quetiapine fumarate or risperidone.

The present analysis assessed the efficacy of extended-release quetiapine fumarate (quetiapine XR) versus risperidone in patients with schizophrenia and depressive symptoms [Hamilton Depression Rating Scale (HAM-D) score≥20 and a HAM-D item 1 score≥2]. This was a subanalysis of patients with schizophrenia from a randomized, open-label, parallel-group, flexible-dose study (NCT00640562) that also enrolled patients with schizoaffective disorder. The primary endpoint of this noninferiority study was change from baseline to week 12 in Calgary Depression Scale for Schizophrenia score (per protocol population). Overall, 114 patients received quetiapine XR (n=60; 400-800 mg/day) or risperidone (n=54; 4-6 mg/day). Change in Calgary Depression Scale for Schizophrenia score was greater for quetiapine XR than for risperidone [least squares means: -7.2 vs. -4.8; treatment difference 2.4 (95% confidence interval 0.3-4.6; P<0.05)]. Adverse events (≥3%) among patients receiving quetiapine XR were sedation, somnolence, and dry mouth, and among those receiving risperidone were anxiety, insomnia, asthenia, hyperprolactinemia, and somnolence. Abnormally high prolactin levels were reported for 57.6 and 8.1% of patients receiving risperidone and quetiapine XR, respectively. Quetiapine XR was superior to risperidone at reducing depressive symptoms in patients with schizophrenia.