Psychiatry - August 2008 - (Page 52)

[update on Alzheimer’s] explained to the patient is having the option to begin medication as early as possible should the results of the screening indicate MCI or early AD. Another benefit to having the screening, should the results indicate MCI or AD, is that the patient can better prepare his or her family for future decisions regarding his or her care. An important disadvantage to undergoing screening that can be explained to the patient is that knowing one has MCI or early AD may significantly and negatively affect quality of life for that up testing so the psychiatrist can initiate medication as soon as possible if or when the patient shows signs of AD. An ethical question psychiatrists may consider when they treat patients with MCI is whether they should prescribe these patients a cholinesterase inhibitor.14 After all, the use of a cholinesterase inhibitor to treat patients with MCI is not evidence based and there are several potential side effects.5,15 The argument in support of its use, however, grows stronger for patients with greater risks of developing AD, such as those psychiatrist can do for the patient.19 The rationale of respecting a patient’s autonomy more when the treatments offer less underlies analogously the use of a “sliding” (as opposed to a uniform) standard for determining a patient’s competency. TREATING PATIENTS WITH EARLY AD When treating a patient with AD, the psychiatrist should always keep in mind that during all stages of this disease, the patient’s quality of life is not determined wholly or even mostly by the extent of his or her cognitive decline. Rather, the quality of life of a patient with AD may be more affected by the quality and extent of his or her social relationships, especially during the earlier stages of AD.20 This does not mean that a patient with AD should force himself or herself to go to every community event or social activity to which he or she is invited, because some events or activities may cause undue stress to the patient.2 Rather, the psychiatrist should encourage the patient with AD to make choices that will reduce exceptional stress, keeping in mind that the things that cause stress to a patient with AD will constantly change.21 Patients with AD and their caregivers and family members should know that while these patients lose cognitive functioning in some areas, other areas of functioning may remain intact.22 Currently, research is being conducted to determine how patients with AD can use their residual strengths to better compensate for their illness.23 In other words, a patient with AD may continue to use the areas of functioning as “islands of strength.” These islands may enable them to offset and compensate for functions the quality of life of a patient with AD may be more affected by the quality and extent of his or her social relationships [than by level of cognitive functioning], especially during the earlier stages of AD.22 individual. A discussion of these pros and cons prior to conducting the screening enhances the patient’s autonomy and employs the insight underlying motivational interviewing: It meets the patient “where he or she is” and tailors the psychiatrist’s clinical intervention to each patient’s present level of accepting or denying that he or she possibly has MCI or AD.10,11 who have genes that predispose them to acquiring AD and/or have positive family histories of AD.1,16,17 The “scientific” judgment to prescribe only evidence-based treatments is one of several ethical judgments that can be made during decision-making processes, such as whether to prescribe a cholinesterase inhibitor. Fully informed patients may believe that a treatment is sufficiently effective for them even though it is not evidence based, especially when their disease is very severe and there are no other treatments. The use of this patient-centered alternative judgment is often referred to as “compassionate use.” This nonevidence-based judgement is particularly common in the treatment of medical issues in children.18 When a patient has a serious illness for which there is no effective treatment other than possibly the one he or she wants to have, respecting his or her autonomy by providing access to this treatment (though it is not evidence based) is one thing the TREATING PATIENTS WITH MCI Once it is determined that a patient has MCI, the psychiatrist should encourage the patient to obtain optimal care for any other medical conditions, such as hypertension, since certain untreated conditions can exacerbate AD. The psychiatrist may also recommend other measures that may possibly be beneficial, such as eating healthy foods, exercising, and engaging in activities that stimulate the brain.12,13 The psychiatrist should also encourage the patient with MCI to continue to come for regular follow52 Psychiatry 2008 [ A U G U S T ]

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Psychiatry - August 2008 Editor’s Message Editorial Advisory Board Contents Borderline Personality Disorder: Are Proliferative Symptoms Characteristic? Short-acting versus Long-acting Medications for the Treatment of ADHD Baby Stimuli and the Parent Brain: Functional Neuroimaging of the Neural Substrates of Parent-Infant Attachment These Boots Are Made for Stalking: Characteristics of Female Stalkers Managing Attention Deficit Hyperactivity Disorder in the Emergency Department Obstructive Sleep Apnea, Hypoxia, and Metabolic Syndrome in Psychiatric and Nonpsychiatric Settings Improving the Quality of Life in Patients with Alzheimer’s Disease The Process of Getting New Drugs to Market Journal Watch Classified Advertising Information for Authors

Psychiatry - August 2008

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