Symptoms mimicking dementia in a 60-year-old woman with bipolar disorder: a case report

How Does Dementia Begin to Manifest in Bipolar Disorder? A Description of Prodromal Clinical and Cognitive Changes

BACKGROUND

Older adults with bipolar disorder (BD) have increased dementia risk, but signs of dementia are difficult to detect in the context of pre-existing deficits inherent to BD.

OBJECTIVE

To identify the emergence of indicators of early dementia in BD.

METHODS

One hundred and fifty-nine non-demented adults with BD from the National Alzheimer's Coordinating Center (NACC) data repository underwent annual neuropsychological assessment up to 14 years (54.0 months average follow-up). Cognitive performance was examined longitudinally with linear mixed-effects models, and yearly differences between incident dementia cases and controls were examined in the six years prior to diagnosis.

RESULTS

Forty participants (25.2%) developed dementia over the follow-up period ('incident dementia cases'). Alzheimer's disease was the most common presumed etiology, though this was likely a result of sampling biases within NACC. Incident dementia cases showed declining trajectories in memory, language, and speeded attention two years prior to dementia onset.

CONCLUSION

In a sample of BD patients enriched for Alzheimer's type dementia, prodromal dementia in BD can be detected up to two years before onset using the same cognitive tests used in psychiatrically-healthy older adults (i.e., measures of verbal recall and fluency). Cognition in the natural course of BD is generally stable, and impairment or marked decline on measures of verbal episodic memory or semantic retrieval may indicate an early neurodegenerative process.

How medical professional students view older people with dementia: Implications for education and practice

Background

Healthcare professionals’ attitudes to older people, and especially those living with dementia, may contribute to unsatisfactory healthcare. Despite repeated calls to address increasing need, training an adequate geriatric workforce remains an international concern. Of particular concern are the attitudes and knowledge healthcare workers may hold about people living with dementia. Students’ knowledge of dementia has been found to be low at the beginning of their university education and has shown limited improvement throughout their coursework; greater understanding of students’ attitudes to ageing and dementia, upon entry and throughout their degrees, may help inform targeted educational interventions to improve the healthcare delivered to older people.

Methods

This study measured knowledge of and attitudes toward dementia and ageing in an Australian university student sample (n = 183), comparing students from medical professional versus non-medical professional related fields at both undergraduate and postgraduate levels. We examined diagnostic and prognostic biases through age manipulation of a vignette describing a hypothetical patient (aged 42 or 72 years), who was experiencing symptoms that were consistent with DSM-5 criteria for both dementia and depression. Based on information provided in the vignette, student participants were asked to select a primary disorder that they would assign to the patient.

Results

Showed that while medical professional students held significantly more positive attitudes toward ageing than 'other' students, average attitudinal scores indicated neutrality. Medical professional students indicated a diagnostic bias toward the older vignette patient, who was more likely to be diagnosed with dementia than depression. A history of geriatric-specific training did not predict dementia knowledge; however, having prior contact with people with dementia predicted both dementia knowledge and more positive prognoses.

Conclusions

Overall, findings indicated medical professional students held neutral attitudes towards older people and showed deficits in knowledge of dementia. Educational interventions that introduce students to people living with dementia may improve knowledge, skills, and attitudes. All university students would benefit from education about dementia and inclusivity to reduce stereotyping and stigma.

Anticholinergic medicines use among older adults before and after initiating dementia medicines

AIMS

We investigated anticholinergic medicines use among older adults initiating dementia medicines.

METHODS

We used Pharmaceutical Benefits Scheme dispensing claims to identify patients who initiated donepezil, rivastigmine, galantamine or memantine between 1 January 2013 and 30 June 2017 (after a period of ≥180 days with no dispensing of these medicines) and remained on therapy for ≥180 days (n = 4393), and dispensed anticholinergic medicines in the 180 days before and after initiating dementia medicines. We further examined anticholinergic medicines prescribed by a prescriber other than the one initiating dementia medicines.

RESULTS

One-third of the study cohort (1439/4393) was exposed to anticholinergic medicines up to 180 days before or after initiating dementia medicines. Among patients exposed to anticholinergic medicines, 46% (659/1439) had the same medicine dispensed before and after initiating dementia medicines. The proportion of patients dispensed anticholinergic medicines increased by 2.5% (95% confidence interval [CI]: 1.3-3.7) after initiating dementia medicines. Antipsychotics use increased by 10.1% (95% CI: 7.6-12.7) after initiating dementia medicines; driven by increased risperidone use (7.3%, 95% CI: 5.3-9.3). Nearly half of patients dispensed anticholinergic medicines in the 180 days after (537/1133), were prescribed anticholinergic medicines by a prescriber other than the one initiating dementia medicines.

CONCLUSION

Use of anticholinergic medicines is common among patients initiating dementia medicines and this occurs against a backdrop of widespread campaigns to reduce irrational medicine combinations in this vulnerable population. Decisions about deprescribing medicines with questionable benefit among patients with dementia may be complicated by conflicting recommendations in prescribing guidelines.