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Detecting Agitation in Patients With Dementia and Alzheimer Disease

A lot of people know the author of Sherlock Holmes is Sir Arthur Conan Doyle, but he was actually Dr Arthur Conan Doyle before he became a writer. He used the medical approach at the time—and that was to be a good detective. This is the type of model we need to think about when we are working with patients who have an underlying major neurocognitive order such as Alzheimer disease with associated agitation. You have to be a good detective to look at all the different potential causes, so I would like to focus specifically on what causes agitation and few tips on how you can get at that.

Keep in mind that by virtue of the fact that someone is suffering from a neurocognitive disorder, they have a brain that is which is damaged. If you look at it on the level of neurocircuitry, a person’s ability to regulate their affect is impaired, their executive function is impaired, and so this in of itself is sufficient to explain why a lot of people end up having exaggerated or inappropriate or disorganized responses to stress given those changes. In addition, we see that some of the key brain nuclei that are involved in the regulation of cognition or mood or behavior such as the serotonergic and dopaminergic systems are also impaired. Again, this also provides a setting for why we see agitated behaviors.

Major factors causing agitation

Clinicians look for several different categories of causes and triggers. One would certainly be medical factors, some either acute or underlying disease state that is impairing brain function. One of the most common causes would be infection, and related to that, delirium. We also look for psychiatric illness. There might be an underlying depression; there could be anxiety, panic attacks, and psychosis which are driving the agitation. We have to look at different psychological factors. Someone may be feeling very stressed out in their environment. There might be an unmet need: are they hungry, thirsty, over-stimulated?

It may be that the caregiver is not competent or is overwhelmed or burned out and so they are not providing the right amount of care or the care they are providing is stimulating agitation in the patient. Finally, we have to look at medication-related issues. Certainly, many different medications (ie, narcotics, steroids), as well as sedating medications (which we think might be helping to treat pain or even relax the person), can actually worsen brain function and could also be associated with agitation.

Dr Agronin is a geriatric psychiatrist and currently serves as the Senior Vice President for Behavioral Health and the Chief Medical office at MIND Institute at Miami Jewish Health in Miami, FL. He is the author of The Dementia Caregiver: A Guide to Caring for Someone with Alzheimer’s Disease and Other Neurocognitive Disorders.


Sidra Goldman-Mellor, Ph.D., from the University of California in Merced, and colleagues examined the one-year incidence of suicide and other mortality among emergency department patients (2009 through 2011) who presented with nonfatal deliberate self-harm, suicidal ideation, or any other chief concern. Sociodemographic and clinical factors associated with suicide mortality risk were examined.

The researchers identified 648,646 individuals (mean [SD] age, 43.8 years; 54.1 percent women) who visited a California emergency department. In the year after index presentation, the rates of suicide deaths per 100,000 person-years were 693.4 deaths among 83,507 individuals presenting with deliberate self-harm (standardized mortality ratio [SMR], 56.8), 384.5 deaths among 67,379 individuals presenting with suicidal ideation but not self-harm (SMR, 31.4), and 23.4 deaths among 497,760 reference patients (SMR, 1.9). The rates of suicide mortality were higher among men (deliberate self-harm: 1,011.1 deaths per 100,000 person-years; suicidal ideation: 539.8 deaths; reference: 36.6 deaths), people aged 65 years or older (deliberate self-harm: 1,919.5 deaths; suicidal ideation: 691.2 deaths; reference: 28.6 deaths), and non-Hispanic white patients (deliberate self-harm: 914.1 deaths; suicidal ideation: 511.6 deaths; reference: 33.8 deaths) versus their respective referent groups.

Read More At: https://consumer.healthday.com/emergency-medicine-23/suicide-health-news-646/suicide-30-to-50-times-higher-after-ed-visit-for-self-harm-suicidal-ideation-753013.html

After a therapy session during which a patient expressed frustration at his job, the therapist relates to these feelings at her own workplace. This feeling of countertransference, or emotional reaction of the therapist to the patient, may be affected by how the therapist hears the patient.
Which of the following is the most likely to exert such an influence on the therapist?

A. The patient’s transference to the therapist

B. The therapist’s conscious conflicts

C. The increased clarity of the therapist’s judgment

D. The developmental period of the therapist’s life

E. The lack of intensity of the transference

The correct response is option D: The developmental period of the therapist’s life.

Countertransference is the emotional reaction of the therapist to the patient. Historically, countertransference was limited in meaning to the therapist’s transference onto the patient.This was felt to be a response to the patient’s transference (option A).

Like all transferences, the therapist’s countertransference was the result of unconscious conflicts (option B); however, these unresolved conflicts were those of the therapists rather than those of the patient. This countertransference was thought to obscure the therapist’s judgment (option C) in conducting the therapy. Countertransference’s are many and varied. Often, they are the result of events occurring in the therapist’s life that may make him or her more sensitive to certain themes in the patient’s associations. The developmental period (option D) of the therapist’s life-involving issues of intimacy, achievement, or old age, for example – may also affect how the therapist hears the patient. Intense transferences (option E) all kinds of erotic, aggressive, devaluing, idealizing, and others – are ripe for serving as stimuli to awaken in the therapist elements of his or her own past

Which of the following anxiety disorders has the oldest median age at onset?

A. Specific

PhobiaB. Panic Disorder

C. Agoraphobia

D. Social Anxiety Disorder

E. Generalized Anxiety Disorder 

The correct response is option E: Generalized Anxiety Disorder.

Among the anxiety disorders, GAD has the oldest median age at onset, at 30 years (option E). Median onset age is 15 years for specific phobia (option A), 23 years for panic disorder (option B), 18 years for agoraphobia (option V), and 15 years for social anxiety disorder (option D).

  • Behavioral Health organizations should ensure that patients receive effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.
  • Behavioral Health organizations should ensure that their staff receive education and training in culturally and linguistically appropriate service standards.
  • Behavioral Health organizations must provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency.
  • Behavioral Health organizations must provide to patients both verbal offers and written notices in their preferred language which inform them of their rights to receive language assistance services.
  • Behavioral Health organizations must assure the competence and the quality of language assistance provided by the interpretation service to any limited English proficient patient.
  • Behavioral Health organizations must make available patient-related materials and post signage in the language of the commonly encountered groups in the service areas. 
Which of the following anxiety disorders has the oldest median age at onset?

A. Specific Phobia
B. Panic Disorder
C. Agoraphobia
D. Social Anxiety Disorder
E. Generalized Anxiety Disorder 

The correct response is option E: Generalized Anxiety Disorder.
Among the anxiety disorders, GAD has the oldest median age at onset, at 30 years (option E).
Median onset age is 15 years for specific phobia (option A).
23 years for panic disorder (option B), 18 years for agoraphobia (option C).
15 years for social anxiety disorder (option D).
School-based health clinics offer a naturalistic environment to provide health care services with unique opportunities for collaboration between educators, primary care clinicians, and behavioral healthcare specialists.

These programs attest to the ability to use Telemental Health Services (TMH) to reach a wide variety of youth across a large geography.

These strengths-based, community-oriented, behavioral health services involve school staff who improve their understating and management of children who reside in rural, remote, and underserved communities.

High-bandwidth Videoconferencing is used to coordinate these services along with telephone connection as a backup when video problems arise as they there is often a lack of tech support at the schools.

Additionally these school-based programs emphasize the involvement of multiple members of the child’s family and support system.

The Telephony allows all the stakeholders in the child’s network to participate without missing work, traveling long distances, or compromising other important duties.

This model also teams up psychiatrists, psychologists, social workers, and counselors to provide continuing education and ongoing training via telephone and videoconferencing targeted to schools, primary care, and behavioral health clinicians.

Each clinic session also provides ample time for the interdisciplinary case discussions and treatment planning of difficult cases.

Which one of the following dimensions on the Temperament and Character Inventory (TCI) is most likely to increase with age? 

A. Cooperativeness.

B. Harm avoidance.

C. Persistence.

D. Reward dependence.

E. Self-transcendence. 

The correct response is A: Cooperativeness 

Personality disorder is associated with younger age and this suggests maturation through greater flexibility with increasing age. In general, three dimensions of personality change substantially with age. Novelty Seeking decreases; Cooperative increases; and Self-Directedness increases.

1. Non-employee professional mental health relationships come in three types: Supervisory, Consultative, and Collaborative. 

 2. In Supervisory relationships, the supervisors retains direct responsibility for the patient and gives the supervisee professional direction and active guidance. The Supervisor is usually paid by the institution providing the supervisee’s training and not by the trainee. The patient is and should be fully informed that the treating provider is being supervised and what that means. If a lawsuit pertaining to the patient’s care arises the supervisor will almost always be named as potentially liable. 

3.In consultative relationships the consultant is asked only for their professional opinion and may or may not examine the patient directly. In mental health practice, the term consultant is often applied to a senior consultant paid directly by the provider for consultation regarding cases. The patient is never examined directly and the advice of the so-called supervisor is given on a strictly take-it-or-leave-it basis. If an examination of the patient does take place, it is often limited to the facts needed to answer the questions posed. Consultants do not control the case and liability is limited because the role in treatment is limited. 

4. In Collaborative relationships two or more providers care simultaneously for a patient. The collaborators may have the same professional degree, as in the case when psychiatrists and primary care physicians see a patient with somatoform disorder, or the professional degrees may be different , as in the case of ” split treatment,” where a psychiatrist sees the patient for medication management and a non-physician sees the patient for psychotherapy. Split-treatment relationships may place the collaborating psychiatrist at increased risk for malpractice. While in theory the Physicians’ liability should be limited to the psychopharmacological aspect of a split treatment, in practice a judge or jury may see the psychiatrist as more responsible for the patient or even consider the therapist an agent of the psychiatrist. To keep the relationship strictly collaborative and to minimize liability any psychiatrist should avoid exerting control over or providing even the appearance of supervising a non-physician therapist. Be sure the patient understands the roles of each provider and also that the therapist is not being supervised by the physician. 

– 5. For all relationship types make sure that all parties are licensed, have good professional reputations, and have adequate malpractice coverage.

1. Fraud is the intentional misrepresentation of facts with the intent to deceive.

2. Misrepresenting the duration of a mental health visit on a claim is one form of fraud. 

3. Fraud may also occur through concealment of a fact that should have been disclosed such as ownership in a company to which the practitioner refers.

4. Fraud also has three other components besides misrepresentation or concealment of the facts – (1) the professional must know that the statement is false, (2) the victim must rely on the false information, and (3) the victim must suffer harm as a consequence of the fraud.

5. Note that in mental health practice the victim may be the insurance company, the government (in the case of Medicare or Medicaid), or the patient.

6. The fiduciary relationship between a mental health provider and a patient makes any misleading statement more likely to qualify as fraudulent because the criteria about reliance on the information and subsequent injury to the patient (in terms of the therapeutic relationship) are almost always met.

7. Fraud may be litigated in either civil or criminal courts depending on the nature of the act and whether recompensation is sought.

8. Billing fraud is usually prosecuted criminally.

9. It is important to note that in criminal and fraud investigations, the psychiatric records of the provider generally are not privileged however the specifics may vary from state to state.