Pimavanserin Treatment for Psychosis in Patients with Dementia with Lewy Bodies: A Case Series.

BACKGROUND Many patients with dementia with Lewy bodies (DLB) experience cholinesterase inhibitor- and antipsychotic-resistant psychosis. The new second-generation antipsychotic pimavanserin has been used with some success in the treatment of psychosis in other forms of dementia, including Alzheimer disease and Parkinson disease dementia. It is possible that pimavanserin may also be useful in the treatment of psychosis in DLB. We sought to describe the disease course and treatment of psychosis in 4 patients with DLB who were prescribed pimavanserin after other medications failed to reduce the frequency or severity of hallucinations and delusions. CASE REPORT This is a case series of 4 male patients (ages 56 to 74 at the beginning of the reports) who developed DLB and psychosis (eg, visual illusions, visual and olfactory hallucinations, and paranoid delusions). All 4 patients were prescribed cholinesterase inhibitors (eg, donepezil or rivastigmine) prior to pimavanserin, and only 1 patient experienced improved psychosis while on cholinesterase inhibitors. All 3 patients who were prescribed first-generation antipsychotics (eg, haloperidol) or traditional second-generation antipsychotics (eg, olanzapine, risperidone, or quetiapine) experienced initial or lasting side effects with no improvement of psychosis. Conversely, all 4 patients tolerated pimavanserin well, and 3 of the 4 patients experienced significant improvement of psychosis (eg, fewer hallucinations, fewer delusions, reduced paranoia, and/or reduced distress or agitation related to hallucinations and delusions) when prescribed pimavanserin. CONCLUSIONS This case series suggests that pimavanserin is tolerable in older males with DLB and that it may be useful for the reduction of distressful hallucinations, delusions, and paranoia in patients with DLB.

Teaching Psychiatric Emergencies Using Simulation: an Experience During the Boot Camp.

OBJECTIVE: The purpose of this study is to prepare fourth-year medical students to recognize psychiatric emergencies using simulation technology. The learning experience is accomplished during the boot camp activity designed to train fourth-year medical students in different competencies before transitioning to residency. METHODS: Ninety-eight fourth-year medical students at Paul L. Foster School of Medicine participated in the boot camp during the 2018-2019 academic year. The participation of the Department of Psychiatry was for a total of four full days divided into 3-h morning and 3-h afternoon sessions with the average of four students per hour per session. The use of high-fidelity simulation and standardized patients to recreate two different clinical scenarios representing acute psychiatric emergencies, followed by structured debriefing, was implemented. Pre- and post-qualitative surveys, which were electronically available via Qualtrics, intended to assess the effectiveness of the curriculum and course teaching modalities during the boot camp. RESULTS: All participants reported improvement on levels of confidence in diagnosis and management of psychiatric emergencies compared with baseline. Overall a statistically significant increase in the Likert score was noted in the post-survey analysis. CONCLUSIONS: Teaching psychiatric emergencies utilizing high-fidelity simulation and standardized patient encounters improved student confidence in several competencies. The increase in student confidence can potentially help the learner in transitioning better to residency.

Differences in Real World Executive Function between Children with Pediatric Bipolar Disorder and Children with ADHD.

BACKGROUND: Recent research evidence suggests that executive function (EF) is impaired in both pediatric bipolar disorder (PBD) and attention deficit-hyperactivity disorder (ADHD), although the underlying cognitive mechanisms are still unclear. In this study we examined EF, including cognitive and emotional control, in three pediatric groups with overlapping symptoms. METHODS: Sixteen children and adolescents with PBD, 17 children and adolescents with ADHD, Type Combined, and 13 children and adolescents with PBD and comorbid ADHD (PBD+ADHD) (mean age=12.70, SD=2.21) were assessed using the Behavioral Rating Inventory of Executive Function - Parental Report (BRIEF-PR), clinical scales and neuropsychological tests of attention, working memory and executive function. RESULTS: All groups showed impairment on the Trails A and B tests. However, there were no significant group differences. On the BRIEF-PR while all three groups were impaired in General Executive Functioning and Metacognition only the two PBD groups revealed more extensive EF dysfunction, in both cognitive and emotional control domains, relative to the ADHD group. Conversely, the ADHD group exhibited selective deficits in cognitive domains such as working memory, planning/organization, monitoring, and metacognition. The two PBD groups showed greater impairment than the ADHD group in the domains of Inhibition, Shifting, Monitoring and Emotional Control. Furthermore, results from regression analyses suggest cognitive predictors of EF impairment in ADHD and mood predictors for inhibition in PBD. CONCLUSIONS: The current results contribute new knowledge on domain-specific similarities and differences in executive dysfunction between PBD, ADHD, and the comorbid phenotype, which may inform the diagnostic process and cognitive intervention.

CONTEXTE: Des données probantes issues de recherches récentes suggèrent que la fonction exécutive (FE) est déficiente dans le trouble bipolaire pédiatrique (TBP) et dans le trouble de déficit de l'attention avec hyperactivité (TDAH), bien que les mécanismes cognitifs sous-jacents ne soient pas encore bien définis. Dans cette étude, nous avons examiné la FE, y compris le contrôle cognitif et émotionnel, dans trois groupes pédiatriques présentant des symptômes se chevauchant. MÉTHODES: Seize enfants et adolescents souffrant de TBP, 17 enfants et adolescents souffrant de TDAH, de type combiné, et 13 enfants et adolescents souffrant de TBP et de TDAH comorbide (TBP+TDAH) (âge moyen = 12,70, ET = 2,21) ont été évalués à l'aide de l'Inventaire de comportements reliés aux fonctions exécutives -- rapport des parents (BRIEF-PR), d'échelles cliniques et de tests neuropsychologiques de l'attention, de la mémoire de travail et de la fonction exécutive. RÉSULTATS: Tous les groupes ont indiqué une déficience aux Trail making tests A et B. Toutefois, il n'y avait pas de différences significatives entre les groupes. Dans le BRIEF-PR, même si les trois groupes étaient déficients dans le fonctionnement exécutif général et la métacognition, seulement les deux groupes de TBP révélaient une dysfonction importante de la FE, dans les deux domaines de contrôle cognitif et émotionnel, relativement au groupe de TDAH. À l'inverse, le groupe de TDAH a révélé des déficits sélectifs dans les domaines cognitifs comme la mémoire de travail, la planification/organisation, la surveillance et la métacognition. Les deux groupes de TBP ont montré une plus grande déficience que le groupe de TDAH dans les domaines de l'inhibition, la flexibilité, la surveillance et le contrôle émotionnel. En outre, les résultats des analyses de régression suggèrent des prédicteurs cognitifs de la déficience de la FE dans le TDAH et des prédicteurs de l'humeur pour l'inhibition dans le TBP. CONCLUSIONS: Les présents résultats contribuent aux nouvelles connaissances sur les similitudes et les différences propres aux domaines en matière de dysfonction exécutive entre le TBP, le TDAH et le phénotype comorbide, ce qui peut éclairer le processus diagnostique et l'intervention cognitive.