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Hallucinations, Delusions, and Antipsychotic Medications

Interview with Dr. Lisa Frank (Part 2)

Episode #029


Dr Regina Koepp:    ...and so this leads me to the question of anti-psychotic medications, which are really complicated, right? Because I hear from families where there's a loved one with dementia. "Oh, my loved one with dementia has had delusions or hallucinations and been prescribed an antipsychotic" or "has not been prescribed an anti-psychotic. Does that mean my doctor is neglecting us?"

Hello there I am Dr Regina Koepp and this is The Caring for Aging Parents show. I'm a board certified clinical psychologist and I specialize in older adults and families. I help you manage the most complicated situations with your aging parents so that you have peace of mind knowing that you are doing everything you can to help your parents live their best lives without giving up your own life in the process. So for the best tips on helping you to care for your aging parents, subscribe to my show and you'll get new tips every Wednesday. As we get started, I wanted to share with you an important freebie I made about dementia. It's called Dementia 101: A Beginner's Guide to Dementia Disorders. In it, I talk about what dementia is and isn't. I describe the phases of dementia and what to do if you're worried that your aging parent may have dementia. I'll link to it in my show notes. So take a minute and download it. It answers some of the most frequently asked questions I get about dementia.

This is the second video of a three part interview with my best friend, Dr. Lisa Frank. Today I'll be interviewing Dr. Frank about the difference between hallucinations and delusions. We'll also be talking about antipsychotic medications and we'll answer the question: "My loved one doesn't have hallucinations or delusions. So why are they prescribed antipsychotics?" Let's get started.


What are hallucinations and delusions?

Dr Regina Koepp:    One of the big questions that I read about a lot on Facebook groups that I belong to with dementia caregivers, and also I see a lot of my own practice with families is this issue of hallucinations and delusions and psychosis. So can you break that down for us? What is psychosis? What is a psychotic disorder? What are hallucinations? What are delusions? HELP!

Dr Lisa Frank:    So psychosis is the umbrella that we'll be talking about. All the pieces underneath psychosis is experiences that are not reality based, under that are hallucinations and delusions. So we'll take hallucinations first. Hallucinations usually are auditory or visual. Auditory are people hear voices...maybe their spouse died a few years before and they're hearing that person's voice. Maybe they're hearing voices that they can't distinguish, but there's no one talking. And so it is a hallucination. So it's not something that they're mishearing it's not that they have hearing impairment, it's that they are experiencing voices or sometimes music or other sounds when there is no auditory stimulus in the environment.

Dr Regina Koepp:    What are some examples of visual hallucinations?

Dr Lisa Frank:    Visual hallucinations are things that people see that are not reality-based. And it's NOT like well I see there's a chair there, but instead of seeing a chair, it looks kind of like a person- there's nothing there and I'm seeing something. So I'm seeing a person, maybe again, a spouse who has passed away before. Or, for things like Lewy body dementia, maybe the person is seeing small children or animals, which is a common visual hallucination in Lewy body dementia. So that's hallucinations. There are other types, olfactory, so smelling things...Tactile (hallucinations). So sometimes people will say they feel like they have bugs crawling on their skin. But, the most common ones that we see are auditory and visual hallucinations.

Dr Regina Koepp:    Okay. And that can happen in a person who has a psychotic disorder like Schizophrenia.. It can also happen in people with dementia disorders. So can you describe a little bit about that?


Hallucinations, Delusions, and Dementia!

Dr Lisa Frank:    We can see a range of psychotic symptoms, hallucinations and delusions in people with different types of dementia. You can also see those things occurring in someone with a delirium. And if there's a sudden change and all of a sudden your mom is seeing people who aren't there and talking to unseen others. And that happened quickly. We're back to delirium. But with dementia, what we commonly see early on are delusions and the technical definition is that they're false beliefs. And so we believe things that are not reality-based. A common one is that someone is stealing from me. So we have a housekeeper who's been coming for years and years and as a trusted person and, and we value his or her input in the family. And now, you know, mom is saying, well, this person is stealing from me and you know that it's not true. But, mom very much believes that. So that would be a paranoid or persecutory delusion. There are other delusions that can occur, where a person with dementia may believe that their spouse is cheating on them. And that's also not true. But it can feel very real for the person. And so what's important with delusions is we say: you never argue with the delusion. That's very challenging for a family member because they want to convince the person, "no, no, no, he's not cheating on you!" But it feels very real for that person. So the best thing to do is to reassure and then redirect to a different topic.


When to treat hallucinations and delusions with dementia?

Dr Regina Koepp:    So can you talk a little bit about...with dementia disorders, when there are hallucinations or delusions, how do you as a psychiatrist decide when and if to treat those?

Dr Lisa Frank:    Right? So the short answer is when they are interfering with the person's ability to receive care when they're very distressing for the person, um, or when they are interfering with safety. So the, the general rule is that we want to use the fewest number of medications possible to give the best effect. And typically anti-psychotics should not be the first line of treatment for hallucinations and delusions only if they are distressing only if they are making the person unsafe, diminishing quality of life or interfering with ability to receive care.

Dr Regina Koepp:    So it's quite possible and even healthy for a psychiatrist or a physician, NOT to prescribe an antipsychotic to a person with dementia who's having a hallucination or delusion. And that's because why? Why could that even be a healthy decision if it's not, if the person is not distressed. So if the person doesn't meet that criteria that you just listed, why might it actually be a healthier decision to not be on an antipsychotic?

Dr Lisa Frank:    Right. So medications in general all have side effects. Anti-psychotics have very unwanted side. And in fact, in patients with dementia, there's a black box warning for a-typical antipsychotics. A-typical antipsychotics are the newer generation, the second generation of antipsychotic medications. The black box warning is because we have found over time that there is an increased risk of death in patients who are prescribed those medications and have an existing diagnosis of dementia. And so they carry a great deal of risk and we are always conscious of balancing risk and benefit. So there has to be a significant benefit to be gained in order to justify the risk of adding that medication.

Dr Regina Koepp:    Okay. So it's not necessarily neglect?

Dr Lisa Frank:    Correct.

Dr Regina Koepp:    It might be actually in the best interest of the person who's experiencing the hallucination or delusion.

Dr Lisa Frank:    Right.

Dr Regina Koepp:    So if they're safe with it. They're not distressed by it. It's not interfering with care. It's not diminishing quality of life. So it might be better just to help redirect, to help focus on other aspects of care and not necessarily need to treat that with an antipsychotic.

Dr Lisa Frank:    Yes.


What is a black box warning?

Dr Regina Koepp:    So a black box warning - this is a big one. We hear it all the time, "but this has black box warning." So that means specifically that what?

Dr Lisa Frank:    There's an FDA warning for this medication for a specific patient population. And in the case of a-typical antipsychotics, there's an increased risk of death related to typically cardiovascular effect, cerebrovascular events, and some types of infection, usually pneumonia or respiratory infections. And that is why these medications are at a higher level of risk for patients with dementia. And so that it doesn't mean that we would not ever use these medications. It means that that we would go through other steps before moving to that medication. And in order for us to prescribe it, we would have a conversation with the person depending on their capacity to understand and the family members so that they understand we're graduating to an increased level of risk with this medication because we've tried these other interventions like behavioral interventions, we've tried less restrictive medications and they haven't worked in, and this person is still having one of these difficulties.


Why is my loved one prescribed an antipsychotic medication when they don't have hallucinations or delusions?

Dr Regina Koepp:    So I hear regularly from that their loved one with dementia is prescribed an anti psychotic medication, but the person with dementia has never had a hallucination or a delusion and there's the family members are concerned, why would they be prescribed anti-psychotic when they don't have any psychotic symptoms? So how does that happen and what kinds of situations does that happen?

Dr Lisa Frank:    So I'm imagining that, that these patients you're talking about are in the later stages of dementia and are perhaps at a skilled nursing facility, maybe in a dementia unit...

Dr Regina Koepp:    or require 24/7 care at home.

Dr Lisa Frank:    Right. Okay. Yeah. So in those cases, other interventions have likely, hopefully been tried. So behavioral interventions have been tried and have been unsuccessful, less complicated, less adverse event associated medications have been tried and have not been effective. And so they've stepped up to the use of perhaps a low dose antipsychotic medication for agitation or behavioral symptoms. And in that case, the provider - the psychiatrist or the primary care doctor - hopefully has had the conversation with the family about the black box warning and why they're moving to that medication.

Dr Regina Koepp:    Okay. So it is possible that a person with dementia is prescribed an anti psychotic, even though they've never had a hallucination or delusion and it's not the physician is harming them, it's that it might be the last resort of things to help with an agitation or disruptions...

Dr Regina Koepp:    okay. So one more question about anti-psychotics. So I see pretty regularly also my patients who have been medically hospitalized and had a delirium and started on an anti-psychotic, even though they had a delirium. So a delirium with a psychotic sort of proof presentation. So can you explain that? Why is an antipsychotic used with delirium and why is it continued even after the person discharges from the medical inpatient unit?


Why are antipsychotic medications prescribed when there is an episode of delirium?

Dr Lisa Frank:    So depending on the cause of the delirium, the person may require treatment with typically a low dose anti-psychotic and so that would be used while they're in the hospital and they would probably be discharged on it because they're still recovering. That medication should be stopped within a few weeks to maybe a month after they're discharged, but sometimes it's not. Um, and that would be important to bring up with the outpatient doctor. But antipsychotics are used for a delirium to treat the delirium.


Wrapping Up!

Dr Regina Koepp:    In wrapping up our episode for today, I wanted to remind you to download that free guide that I created just for you called Dementia 101: A Beginner's Guide to Dementia Disorders. So join me and Dr. Frank next week for our final video where we talk about older adults and older adults with dementia who are receiving care on a psychiatric inpatient unit. So we'll be talking about how you as a family member can help your loved one while they're on a psychiatric inpatient unit and even help with the discharge planning and finding mental health providers in the community. So if this video was helpful, be sure to subscribe and don't forget to share this video with your friends who are caring for their aging parents because nobody should have to do this caregiving-thing alone. Lots of love to you and your family. I'll see you next Wednesday.



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