Understanding the role of psychiatrists in the diagnosis and management of mild cognitive impairment and mild Alzheimer's disease dementia: a cross-sectional survey.

BACKGROUND: Alzheimer's disease (AD) is a progressive neurological disorder and the most common cause of dementia. The clinical continuum of AD ranges from asymptomatic disease to mild cognitive impairment (MCI), followed by AD dementia, categorized as mild, moderate, or severe. Almost one-third of patients suspected of having MCI or mild AD dementia are referred to specialists including psychiatrists. We sought to better understand the role that psychiatrists play in the diagnosis, treatment, and management of patients with all-cause MCI or mild AD dementia. METHODS: We conducted an anonymous, online survey among physicians in the United States between February 4, 2021, and March 1, 2021. We surveyed psychiatrists, primary care physicians (PCPs), geriatricians, and neurologists who treat patients with all-cause MCI or mild AD dementia. RESULTS: A total of 301 physicians participated in the survey, 50 of whom were psychiatrists. Of their patients with all-cause MCI or mild AD dementia, psychiatrists reported personally diagnosing two-thirds (67%). Psychiatrists used various methods to diagnose MCI or mild AD dementia including mental status testing (94%), review of patient medical history (86%), and neurological exams (61%). Upon diagnosis, psychiatrists reported most commonly discussing treatments (86%), management strategies (80%), disease progression (72%), and etiology of MCI or mild AD dementia (72%) with their patients. Most psychiatrists surveyed (82%) reported receiving advanced formal training in MCI and AD dementia care, primarily via residency training (38%), continuing medical education (22%) or fellowship (18%). Additionally, almost all psychiatrists (92%) reported receiving referrals for ongoing management of patients with MCI or mild AD dementia, primarily from PCPs or neurologists. However, only 46% of psychiatrists viewed themselves as the coordinator of care for their patients with MCI or mild AD dementia. CONCLUSIONS: Many psychiatrists indicated that they were well-informed about MCI and AD dementia and have a strong interest in providing care for these patients. They can provide timely and accurate diagnosis of clinical MCI and mild AD dementia and develop optimal treatment plans for patients. Although many psychiatrists consider other physicians to be the care coordinators for patients with MCI and mild AD dementia, psychiatrists can play a key role in diagnosing and managing patients with MCI and mild AD dementia.

Alzheimer's disease (AD) is the most common cause of dementia. Symptoms of AD include a decline in memory, language, problem-solving, and other thinking abilities that affect daily life. AD may first appear as mild cognitive impairment (MCI) but eventually progresses to AD dementia which is categorized as mild, moderate, or severe based on how much symptoms interfere with patients' everyday activities. We wanted to better understand the roles of different types of doctors in the diagnosis and management of MCI and mild AD dementia. A total of 301 doctors in the United States took an online survey in 2021. Of these, 50 were psychiatrists who specialize in mental health. Psychiatrists used several methods to diagnose patients with MCI or mild AD dementia, including mental status and memory testing. At diagnosis, psychiatrists discussed various topics with their patients who have MCI or mild AD dementia, including treatment options, ways to manage the disease, cause of the disease, and its progression. After diagnosis, most psychiatrists saw their patients with MCI or mild AD dementia at least four times a year. Most psychiatrists reported having advanced training in MCI and AD dementia care. Almost all psychiatrists said other doctors refer patients to them for ongoing management. However, less than half of psychiatrists consider themselves to be the coordinator of care for their patients with MCI or mild AD dementia. As physicians with training in MCI and AD dementia care, psychiatrists can play an important role in the timely diagnosis, treatment, and management of MCI and mild AD dementia.

Perspectives of patients, care partners, and primary care physicians on management of mild cognitive impairment and mild Alzheimer's disease dementia.

OBJECTIVES: Early diagnosis of mild cognitive impairment (MCI) and mild Alzheimer's disease (AD) dementia is crucial for effective disease management and optimizing patient outcomes. We sought to better understand the MCI and mild AD dementia medical journey from the perspective of patients, care partners, and physicians. METHODS: We conducted online surveys in the United States among patients/care partners and physicians in 2021. RESULTS: 103 patients with all-cause MCI or mild AD dementia aged 46-90 years, 150 care partners for someone with all-cause MCI or mild AD dementia, and 301 physicians (101 of which were primary care physicians, [PCPs]) completed surveys. Most patient/care partners reported that experiencing forgetfulness (71%) and short-term memory loss (68%) occurred before talking to a healthcare professional. Most patients (73%) followed a common medical journey, in which the initial discussion with a PCP took place 15 months after symptom onset. However, only 33% and 39% were diagnosed and treated by a PCP, respectively. Most (74%) PCPs viewed themselves as coordinators of care for their patients with MCI and mild AD dementia. Over one-third (37%) of patients/care partners viewed PCPs as the care coordinator. CONCLUSIONS: PCPs play a vital role in the timely diagnosis and treatment of MCI and mild AD dementia but often are not considered the care coordinator. For the majority of patients, the initial discussion with a PCP took place 15 months after symptom onset; therefore, it is important to educate patients/care partners and PCPs on MCI and AD risk factors, early symptom recognition, and the need for early diagnosis and treatment. PCPs could improve patient care and outcomes by building their understanding of the need for early AD diagnosis and treatment and improving the efficiency of the patient medical journey by serving as coordinators of care.

Alzheimer's disease (AD) is not a normal part of aging, but many people develop AD as they age, and it is the seventh leading cause of death in the US. AD is a neurological condition that begins as mild cognitive impairment (MCI) or mild AD dementia. To understand the medical journey of patients with MCI or mild AD dementia, we surveyed 103 patients with MCI or mild AD dementia, 150 care partners, and 301 doctors. Patients had several symptoms before talking to a doctor, including forgetfulness and short-term memory loss; most patients (64%) first discussed these symptoms with a primary care physician (PCP) on average 15 months later. However, most patients were not diagnosed or treated by a PCP for MCI or mild AD dementia. We asked patients/care partners who they believe is the coordinator of their care for MCI and mild AD dementia. Thirty-seven percent felt the PCP was the coordinator of care. Most surveyed PCPs (74%) considered themselves to be the coordinator of care for their patients with MCI or mild AD dementia. In conclusion, PCPs play a key role in the care of patients with MCI and mild AD dementia. It is important for patients and care partners to understand the symptoms of MCI and mild AD dementia, and the need to get a diagnosis and treatment soon after symptoms appear. PCPs can play an important role in early diagnosis and treatment and serve as coordinators of care for their patients with MCI and mild AD dementia.[Figure: see text].

Cannabinoids in the management of frontotemporal dementia: a case series.

Background: Frontotemporal dementia (FTD) is characterized by progressive deterioration in behaviors, executive function and/or language. The behavioral variant (Bv) is characterized by disinhibition and obsessive/compulsive behaviors. These symptoms are sometimes resistant to medications. This series examines patients suffering with treatment-resistant Bv-FTD who were prescribed cannabinoid and related compounds for other indications. Case presentation: Three FTD cases from a dementia clinic were identified. These patients had disability due to behavior despite typical pharmacologic management. These patients were prescribed marijuana for comorbidities (anxiety, insomnia and pain). In all cases, use of cannabinoid products showed significant improvements in behavior and in the primary indication for prescription. Conclusion: Review of these cases demonstrates potential for the use of cannabinoids in the management of treatment-resistant Bv-FTD.

No MMSE for You! A Case of an "Uncooperative" Patient With Early-Onset Dementia.

The Banner Alzheimer's Institute Case Conference is a weekly event in which physicians and staff discuss challenging and/or teaching cases of patients seen at the Institute's Stead Family Memory Clinic. These conferences are attended by a multidisciplinary group that includes Banner Alzheimer's Institute dementia specialists, community physicians (internal medicine, family medicine, and radiology), physician assistants, social workers, nurses, medical students, residents, and fellows. The Banner Alzheimer's Institute located in Phoenix, Arizona, has an unusually ambitious mission: to end Alzheimer's disease without losing a generation, set a new standard of care for patients and families, and forge a model of collaboration in biomedical research. The Institute provides high-level care and treatment for patients affected by Alzheimer's disease, dementia, and related disorders. In addition, the Institute offers extensive support services for families and many unique and rewarding research opportunities.

Watch-Dog: Detecting Self-Harming Activities From Wrist Worn Accelerometers.

In a 2012 survey, in the United States alone, there were more than 35 000 reported suicides with approximately 1800 of being psychiatric inpatients. Recent Centers for Disease Control and Prevention (CDC) reports indicate an upward trend in these numbers. In psychiatric facilities, staff perform intermittent or continuous observation of patients manually in order to prevent such tragedies, but studies show that they are insufficient, and also consume staff time and resources. In this paper, we present the Watch-Dog system, to address the problem of detecting self-harming activities when attempted by in-patients in clinical settings. Watch-Dog comprises of three key components-Data sensed by tiny accelerometer sensors worn on wrists of subjects; an efficient algorithm to classify whether a user is active versus dormant (i.e., performing a physical activity versus not performing any activity); and a novel decision selection algorithm based on random forests and continuity indices for fine grained activity classification. With data acquired from 11 subjects performing a series of activities (both self-harming and otherwise), Watch-Dog achieves a classification accuracy of , , and for same-user 10-fold cross-validation, cross-user 10-fold cross-validation, and cross-user leave-one-out evaluation, respectively. We believe that the problem addressed in this paper is practical, important, and timely. We also believe that our proposed system is practically deployable, and related discussions are provided in this paper.

Update on New and Emerging Treatments for Schizophrenia.

Although there has been more than 50 years of development, there remains a great need for better antipsychotic medications. This article looks at the recent advances in treatment of schizophrenia. New hypotheses have been suggested that may replace or complement the dopamine hypotheses. The article explores the different novel drugs that impact some of the key neurotransmitter systems currently. Phosphodiesterase 10A inhibitors and α-7 neuronal nicotinic acetylcholine receptor modulators constitute the majority. The marketing of these medications eventually may result in change about how schizophrenia is treated.

Aripiprazole Lauroxil Long-Acting Injectable: The Latest Addition to Second-Generation Long-Acting Agents.

Antipsychotics have long been the mainstay for the treatment of schizophrenia and other psychotic disorders. Long-acting injectables (LAI) of antipsychotics-provided once every two weeks to once every three months-promise to reduce the incidence of nonadherence. ARISTADA(™) (aripiprazole lauroxil; ALLAI) extended-release injectable suspension was approved by the U.S. Food and Drug Administration in October 2015 for the treatment of schizophrenia, and is the newest entrant in the LAI market. ALLAI is available as a single-use, pre-filled syringe, can be started in three different dosages, and also has the option of every six-week dosing. Treatment with oral aripiprazole is recommended for the first twenty-one days after the first ALLAI injection, which is a potential disadvantage. Adverse effects include sensitivity to extrapyramidal symptoms, especially akathisia, which is well documented in other aripiprazole preparations. There is no available data comparing ALLAI to other antipsychotics, and more head-to-head trials comparing different LAI formulations are needed. Based on the available data, ALLAI is an effective and safe option for treatment of schizophrenia. Further studies and post-marketing data will provide better understanding of this formulation.

Two Case Reports on Use of Prazosin for Drug Dreams.

Substance abuse and dependence is estimated to cost roughly $700 billion annually including direct and indirect care in the United States. Drug dreams (DD), or using dreams, are a reportedly common phenomenon among patients with substance abuse, and have been postulated as triggers for relapse. Prazosin is an alpha-1 receptor antagonist originally approved by the United States Food and Drug Administration for the treatment of hypertension. Prazosin passes the blood brain barrier easily, contributing to central and cognitive effects. Prazosin's efficacy has been demonstrated in the management of posttraumatic stress disorder (PTSD), and associated nightmares. We present the cases of two patients with substance use disorder experiencing DD which resolved after the addition of prazosin during an acute psychiatric hospitalization. To our knowledge, this is the first time treatment of DD with prazosin has been reported in the literature. Both patients reported an alleviation of their DD after the medication was initiated. The effect was immediate and results were seen on the same night of the initial dose. The precise mechanism of this effect is unclear, but we hypothesize it is related to the decrease in noradrenaline effects at α-1 adrenoreceptors in the brain, similar to the effect on nightmares in PTSD. The key limitation is the low number of patients and lack of follow up presented in this report. No causal relationship can be established between the use of prazosin and resolution of DD in our patients.

Predictors of length of stay in a psychiatric hospital.

OBJECTIVE: This article reviews the available evidence for predicting length of stay in a psychiatric hospital based on several patient characteristics. METHODS: An OVID Medline search was done for studies in this area with terms: length of stay, acute psychiatric hospital and predictors. Indexed articles were searched for additional references and subsequently cross referenced. The variables described in various studies were classified into demographic, diagnostic, treatment related and system-based variables ( Table 1 ). RESULTS: Substance abuse has been consistently shown to be associated with a shorter length of stay. Mood and psychotic disorders have shown to lengthen the stay in an acute psychiatric hospital. Women tend to stay longer in an acute psychiatric hospital. Other demographic variables like age and education have had equivocal results, while a married marital status and employment are consistently related to a shorter length of stay. Use of restraints and ECT during hospitalization has shown to lengthen the stay in the hospital. CONCLUSIONS: Many studies have explored the relationship between the demographics, diagnosis and treatment variables on length of stay in an acute psychiatric hospital. These studies have been able to account for about 10-37% of the variance in the length of stay. The relevant findings impacting the length of stay are shown in Table 2 .

Long-acting injectable aripiprazole: how might it fit in our tool box?

Schizophrenia is a severe mental illness with a lifetime prevalence of approximately one percent worldwide. Maintenance antipsychotic treatment has been effective in preventing relapses in long-term follow-up studies. Logically it can be proposed that long-acting injectable antipsychotics (LAI) might reduce both unintentional and intentional nonadherence. Long-acting injectable aripiprazole was approved for the treatment of schizophrenia by the U.S. FDA on 28th February 2013 and will be marketed under the name Abilify Maintena. Aripiprazole LAI (ALAI) is a lyophilized powder that needs to be reconstituted with sterile water to form an injectable suspension without affecting the original molecule. The monthly injection interval is very attractive since patients prefer fewer injections. From a tolerability perspective, ALAI appears to be both weight neutral and lacking metabolic side effects. This can confer an advantage over the other currently available second-generation antipsychotic LAIs. Simple constitution with sterile water and no requirement to refrigerate make storage and administration easier. Like all medications, there are always potential disadvantages to ALAI. There is a period of oral coverage, while not as long as for long-acting risperidone microspheres (RLAI), that is required. Care must be taken to review concomitant medications for the presence of metabolic inducers and inhibitors. One would also expect some patients to be sensitive to extrapyramidal symptoms, especially akathisia which is well documented in the oral preparation. All things considered, we welcome our new tool, ALAI, to our work-place and predict both clinical practice and post marketing analysis and studies will discover its true value.