1–4 Patients may experience the hallucinations and delusions that characterize dementia-related psychosis regardless of the underlying disease causing dementia. The cognitive decline exhibited by patients with dementia is often accompanied by neuropsychiatric symptoms, including psychosis, aggression, agitation, depression, and apathy.
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Early diagnosis of dementia-related psychosis and new treatment options for managing hallucinations and delusions are needed to improve care of this patient population. Observations: For residents in long-term care facilities, the following factors can hinder management of hallucinations and delusions related to dementia: (1) delayed recognition of symptoms (2) reluctance of staff and family members to acknowledge psychiatric issues (3) lack of approved pharmacotherapies to treat hallucinations and delusions associated with dementia-related psychosis and (4) regulatory and institutional guidelines, including the long-term care regulatory guidelines established by the Centers for Medicare and Medicaid Services and the 5-star rating system.Ĭonclusions and Relevance: Barriers to the treatment of hallucinations and delusions in patients with dementia in the long-term care setting are myriad and complex. Many people with dementia reside in long-term care facilities, and identification and management of hallucinations and delusions in this setting are critical. These symptoms have been associated with worse outcomes compared with dementia alone, including accelerated functional decline and mortality. Across dementia subtypes, hallucinations and delusions are common, though their prevalence and presentation may vary. It is clear that on the basis of these findings, as has been recognised at least since the 1960s, that even apparently focal epileptic seizures, (especially in the mesial temporal lobe, insula and limbic cortices), must involve widely distributed neuronal networks.Importance: Most people with dementia will experience neuropsychiatric symptoms, including psychosis characterized by hallucinations and delusions. Involvement of the limbic cortex is a pre-requisite for the occurrence of complex hallucinatory states. The most anatomically specific areas from this point of view are the elementary hallucinations arising from primary visual and auditory cortices.
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This lack of specificity applies particularly to psychic symptoms, including experiential phenomena, and complex hallucinatory states. Repeated seizures or stimulation of a single area, even within the same patient can produce different psychic responses, whilst stimulation of widely distinct areas (especially in the limbic system) within the same individual can produce remarkably similar phenomena. First, it is clear that there is only limited anatomical specificity of many hallucinatory states. The wide range of hallucinatory symptoms occurring during epileptic seizures recorded during intracranial SEEG and brain stimulation are reviewed here, including: experiential and interpretive phenomena, affective symptoms, as well as auditory, olfactory, gustatory, somatic and visual hallucinatory phenomena. However, as discussed in the second paper, some psychotic states are associated with similar electrophysiological changes. The semiologically derived differentiation of these terms in psychiatry is not supported by similarly discrete electrophysiological signatures. The neurological approach leads to a more synoptical definition of 'hallucination' than in psychiatry and to the conclusion that there is little point in differentiating hallucination from illusion or delusion in view of the overlap in the physiological bases of the phenomena. The focus of neurology has been to regard delusions, illusions and hallucinations in epilepsy as a result of localised or network based neuronal epileptic activity that can be investigated especially using intracranial stereoelectroencephalography (SEEG). These distinctions in psychiatry have stood the test of time and are useful in clinical descriptive terms, but do not help to understand the basic mechanisms. Psychiatry makes clear distinctions between the terms and has focussed on the empirical use of descriptive psychopathology in order to delineate the various psychiatric syndromes, including those in epilepsy. Regarding definition, there is a clearly divergent evolution in meaning of the terms delusion, illusion and hallucination in the separate traditions of neurology and psychiatry. In this paper, we consider definitions and elementary hallucinatory phenomena. We emphasise the clinical and electrophysiological features, and make comparisons with the primary psychoses. The purpose of this paper and its pair is to provide a comprehensive review, from the different perspectives of neurology and neuropsychiatry, of the phenomenology and mechanisms of hallucinatory experience in epilepsy.