Applying Patient Cases of Late-Life Psychosis to Clinical Practice

In part 2 of this video, Vimal Aga, MD, Embedded Geriatric Psychiatrist, Department of Neurology, Oregon Health and Science University, Portland, Oregon, discusses his recent presentation at the American Psychiatric Association (APA) Annual Meeting “Psychosis in Dementia or Dementia in Psychosis? A Clinical Approach to Late-Life Psychosis and Cognitive Decline.”

Dr. Aga discusses how the lessons he learned from a patient's case can be applied to clinical practice, and other practical implications from his session.

Q: Can you now briefly share one of the patient cases that you discussed in your presentation and how the lessons learned can be applied to clinical practice?

A: For those of you who were not able to be at my talk, I'm just going to go over the case briefly. This is the case of a 72-year-old widowed Caucasian female. She was a high school graduate, never in the service, who had progressively increasing delusions of persecution and visual hallucinations.

She was being followed by a group of people who were harassing her. They were messing with her back yard. They were shining lights into her bedroom, and she only saw these people in dim light. She had installed security cameras. She had called the police on these people several times, but of course, no such people had been found.

She had never made any move to approach these people, but she had threatened to use her on BB gun on them if the "harassment" continued. In terms of cognitive deficits, she had increasing word-finding problems.

She was reporting minimal verbal memory impairment and no visual-spatial deficits. All of these started after the onset of the psychotic symptoms. In the past, she had a long history of anxiety and depression, which appeared to be in partial remission.

The relevant medical history included hypertension, hyperlipidemia. She had a history of obstructive sleep apnea, but was not using a CPAP. Then she had had one TIA in 2009. In terms of relevant family history, she had late-onset dementia in her maternal grandmother in her 90s, but her own mother was still alive and relatively cognitively intact, which was interesting.

On exam, she had some Parkinsonian features in terms of a stooped posture and reduced arm swing on the right. On clinical screening, she had mild depression on the geriatric depression scale, with a score of 6 out of 15. On office cognitive screening, she had prominent problems with confrontation naming and short-term memory impairment.

We used the Cognistat in the clinic to do cognitive screening, and then we sent her for neuropsychological testing, and she had significant impairment in expressive language, including both naming and verbal fluency, verbal memory, attention, and processing speed, and there was minimal functional decline. Let's talk about this case a little bit.

Clinically, at first blush, the patient appears to have DLB, dementia with Lewy bodies, with delusions of persecution, prominent visual hallucinations that only appear to be in dim light or at night. Then she also had symptoms that didn't quite fit into the typical DLB symptomatology, such as increasing word-finding problems.

There was also absence of visual-spatial impairment, which you do not expect to find in DLB cases. Then she had a long history of anxiety and depression, which makes the case relevant to practicing psychiatrists and psychiatric NPs.

There were Parkinsonian features, which again suggest DLB, but there were also problems with confrontation naming on cognitive screening that did not quite fit the DLB diagnosis. Neuropsychological testing also identified problems with verbal memory, attention, and processing speed.

At this point, we are looking at a differential that includes Alzheimer's disease dementia, dementia with Lewy bodies, and vascular cognitive impairment, given her history of

hypertension, hyperlipidemia, obstructive sleep apnea, not using the CPAP, and one TIA in 2009.

The clinician now has to decide on the optimal diagnostic workup, which should also, of course, be cost-effective. What we ended up doing was structural and functional imaging, so an MRI scan of the brain, and also an FDG PET scan of the brain.

We also sent her for CSF Alzheimer's disease biomarker testing, and the structural imaging and the functional imaging were both consistent with an Alzheimer's disease diagnosis. CSF biomarkers were a little more interesting, because her amyloid beta-42 was slightly higher than where it should have been.

The cutoff is 500, and she was 547.75. Given the increase in phospho tau and the low amyloid tau index...Megan, I'm going to do this section again.

The amyloid beta-42 was slightly above the cutoff of 500. It was 547.75. Given that she had an elevated phospho tau and a low amyloid tau index, as well as the entire clinical presentation, the findings on structural imaging and the FDG PET scan, we went with a diagnosis of Alzheimer's disease.

We did not diagnose her with dementia, because there was minimal functional impairment. The final diagnosis was mild cognitive impairment, or mild neurocognitive disorder due to Alzheimer's disease. This case really exemplifies the breadth of knowledge that the clinician must have in working with dementia patients.

Which includes not only core psychiatric concepts, but also how to order and interpret neuropsychological testing, neuroimaging studies, and CSF biomarkers in dementia patients.

Q: The next question is, do you have other practical implications for clinicians that you could talk on and touch on?

A: The practical implications, I think, are threefold, which is first, become really familiar with the latest research and diagnostic criteria for the various dementias. DSM-5, as you might recall, came out in 2013, and there has been a lot of new research into dementia since then.

Second, consider the possibility of an underlying dementia in all late-life psychosis cases. Test for that, as well as in patients with longstanding primary psychotic disorders who are now developing cognitive symptoms.

Then finally, learn how to order and interpret neuropsychological testing, neuroimaging, and CSF studies in dementia patients by first reading up about it, attending meetings like the APA meeting, and then finally getting a mentor who can help you navigate your way through this, if you're new to this.

Q: Are there any misconceptions on this topic that you would like to clear up?

A: The one main misconception I see when talking with other clinicians about dementia patients is that they think working with dementia patients is boring. It's tedious, it's monotonous. I can show you that it's anything but.

Those working with older adults, be they in geriatric psychiatry or geriatric medicine, find the work to be incredibly rewarding, interesting, and intellectually stimulating. Therefore, they have some of the lowest rates of burnout in the medical field.

Q: Do you have any final thoughts or any closing comments?

A: Here are my final thoughts. Our older adult population is exploding, like I've said, and we need more clinicians dedicated to working with them. We need you in the audience to think about entering the field, so that the older adults, maybe the ones in your own life, like your parents, your grandparents, can benefit from your expertise and clinical knowledge in this area.

Especially if they are medical students, residents, and nurse practitioners in training watching this video, please think about choosing a career in geriatric psychiatry, because I can assure you it's going to be really rewarding. Thank you so much for your time, and thanks for watching this.

Vimal Aga, MD is a board-certified Embedded Geriatric Psychiatrist in the Department of Neurology at Oregon Health and Science University, Portland, Oregon. Additionally, he is a psychiatric hospitalist in the Geriatric Psychiatry Program at Oregon State Hospital, Salem, Oregon.