Barriers to Treatment of Hallucinations and Delusions in People With Dementia Residing in Long-Term Care.

Importance: Most people with dementia will experience neuropsychiatric symptoms, including psychosis characterized by hallucinations and delusions. Across dementia subtypes, hallucinations and delusions are common, though their prevalence and presentation may vary. These symptoms have been associated with worse outcomes compared with dementia alone, including accelerated functional decline and mortality. Many people with dementia reside in long-term care facilities, and identification and management of hallucinations and delusions in this setting are critical.Observations: For residents in long-term care facilities, the following factors can hinder management of hallucinations and delusions related to dementia: (1) delayed recognition of symptoms; (2) reluctance of staff and family members to acknowledge psychiatric issues; (3) lack of approved pharmacotherapies to treat hallucinations and delusions associated with dementia-related psychosis; and (4) regulatory and institutional guidelines, including the long-term care regulatory guidelines established by the Centers for Medicare and Medicaid Services and the 5-star rating system.Conclusions and Relevance: Barriers to the treatment of hallucinations and delusions in patients with dementia in the long-term care setting are myriad and complex. Early diagnosis of dementia-related psychosis and new treatment options for managing hallucinations and delusions are needed to improve care of this patient population.

Early Psychiatric Consultation Is Associated With Decreased Cost and Length of Stay in the Patient Population at a Level I Trauma Center.

Introduction Psychiatric illness impacts nearly one-quarter of the US population. Few studies have evaluated the impact of psychiatric illness on in-hospital trauma patient care. In this study, we conducted a retrospective cohort study to evaluate hospital resource utilization for trauma patients with comorbid psychiatric illnesses. Methodology Trauma patients admitted to a level I center over a one-year period were included in the study. Patients were categorized into one of three groups: (1) no psychiatric history or in-hospital psychiatric service consultation; (2) psychiatric history but no psychiatric service consultation; and (3) psychiatric service consultation. Time to psychiatric service consultation was calculated and considered early if occurring on the day of or the day following admission. Patient demographics, outcomes, and resource utilization were compared between the three groups. Results A total of 1,807 patients were included in the study (n = 1,204, 66.6% no psychiatric condition; n = 508, 28.1% psychiatric condition without in-hospital psychiatric service consultation; and n = 95, 5.3% in-hospital psychiatric service consultation). Patients requiring psychiatric service consultation were the youngest (P < .001), with the highest injury severity (P = .024), the longest hospital length of stay (P < .001), and the highest median hospital cost (P < .001). Early psychiatric service consultation was associated with an average saving in-hospital length of stay of 2.9 days (P = .021) and an average hospital cost saving of $7,525 (P = .046). Conclusion One-third of our trauma population had an existing psychiatric diagnosis or required psychiatric service consultation. Resource utilization was higher for patients requiring consultation. Early consultation was associated with a savings of hospital length of stay and cost.

Malingering Imposed on Another: A Diagnosis That is Missing in Action?

BACKGROUND: Descriptions of malingering imposed on another, in which an individual induces or exaggerates symptoms in another for secondary gain (including financial benefit or access to medications), are remarkably scant in the current literature. We summarize reported cases of malingering imposed on another in order to underscore its relevance to practicing physicians. OBJECTIVE: We sought to review the available literature describing the creation or exaggeration of symptoms of illness, motivated by secondary gain, in another vulnerable individual. METHOD: A search of the literature using PubMed was undertaken searching the terms "malingering," "by proxy," and "imposed on another." RESULTS: Malingering imposed on another may be under-reported in the professional literature. Maintaining awareness that caregivers may misrepresent or embellish the symptoms of the identified patient for their own gain is an important consideration to forestall unnecessary testing, hospital admission, and exposure to adverse effects of treatments.

A retrospective study of polyallergy as a marker of nonepileptic seizures in the epilepsy monitoring unit.

BACKGROUND: Distinguishing epileptic seizures from nonepileptic seizures (NES) can be difficult, given their similar motoric manifestations and a common comorbidity. Although video electroencephalography in an epilepsy monitoring unit ideally remains the gold standard for the identification of NES, a number of "soft signs" have been proposed to indicate a greater likelihood that convulsive episodes are NES rather than epileptic in nature. Trainees at our institution have cited the presence of multiple listed allergies as indicative of a higher likelihood of NES. OBJECTIVE: The goal of this study was to provide a statistical analysis of polyallergy and its association with patients with NES admitted for video electroencephalograph monitoring. METHODS: Records of all epilepsy monitoring unit patients at St. Joseph's Hospital and Medical Center between 2006 and 2012 were reviewed for age, sex, electroencephalograph diagnosis, antiepileptic drugs previously tried, and allergy number. RESULTS: A total of 1834 patient records were used for analysis. The group classified as nonepileptic had the highest average number of allergies at 1.56, whereas the group classified as epileptic had the lowest average number of allergies at 0.70. A logistic regression model revealed that for every increase in the number of allergies greater than zero, the odds of being nonepileptic increases by 1.38 times. CONCLUSIONS: This study supports polyallergy as a predictive sign for NES. Based on a logistic regression model, we claim that each additional allergy is associated with an increase in the likelihood of a nonepileptic diagnosis by 38%.

Dermatologic side effects of psychotropic medications.

BACKGROUND: Although relatively uncommon, cutaneous reactions to psychotropic medications may thwart treatment of psychiatric illness and confuse diagnostic efforts especially when they occur in the context of comorbid medical conditions. Psychiatrists may be asked to comment on whether a particular cutaneous condition is due to a psychotropic medication or to recommend a replacement psychotropic agent. OBJECTIVE: To review the available literature describing cutaneous adverse effects prompted by psychotropic medications. METHOD: A search of the literature using PubMed was undertaken using the terms "psychotropic," "psychiatric," "antidepressant," "anxiolytic," "mood stabilizer," "antipsychotic," and "neuroleptic" in combination with either of the terms "dermatologic," "cutaneous" or "skin." RESULTS: Psychotropic medications from all classes have been associated with a broad variety of dermatologic reactions with variable rates of incidence. Psychiatrists should be aware of the potential cutaneous adverse effects of the medications they prescribe. Psychiatrists practicing in the general hospital, where cutaneous symptoms may present for any number of reasons, should be aware of the typical presentations and relative likelihood of these reactions to forestall unnecessary "blaming" of psychotropics for cutaneous reactions.