Nowadays, with our increasingly aged population, it is probable that the main cause of psychotic symptoms in the West is dementia. But what is less obvious is that most of the symptoms of demented patients may actually be due to delirium (that is, to acute confusional states).
The main causes of dementia are probably Alzheimer’s disease pathology (plaques and tangles), Lewy Body pathology (associated with Parkinson’s disease) and multiple strokes (atherosclerosis).
But much of the clinical pathology of dementia is very likely associated with delirium/acute confusion added on top of the dementia: because dementia greatly increases the susceptibility to delirium.
And delirium is, in principle, treatable, improvable.
Just think how often it is observed that demented patients get better from time to time (not completely better, but much improved), and have a few good days, or at least a good few hours.
This strongly suggests that these ‘good times’ are the clinical picture of dementia without the delirium – and that most of the time these patients are delirious.
In an old and demented brain, suffering from degenerative disease, it takes little to flip into delirium – this can be triggered by drug treatment and drug interactions, an infection, dehydration, lack of sleep or disturbed sleep, trauma, underlying tumour, autoimmune disease, or subtle degrees of any disease – hormonal, of a major organ system, and so on..
If – although this may be impossible in practice – all these potential causes of delirium could be checked and treated, restored to normal – I suspect that much of the apparent ‘dementia’ would be relieved.
Greater attention to encouraging regular and restorative sleep (in particular) and hydration, and much greater attention to the perils of drug treatment might help many specific individuals?
This matter of a super-added psychopathology in dementia is usually conceptualised in terms of ‘depression’ – yet this is misleading. In the first place, mainstream psychiatry has no coherent concept of what it means by ‘depression’ – so this is not an explanation at all, but rather a suggestion for ‘antidepressant’ treatment.
And if the real problem is delirium, then many ‘antidepressants’ are likely to worsen the situation, especially due to anticholinergic side effects. In the elderly and demented drug side effects are much commoner and more significant (and harder to rule out) than commonly realized.
On the other hand, there are suggestive reports of demented patients (of various types) benefiting from treatment with electroconvulsive/ electroshock therapy. In particular, ECT seems to help some patients with ‘Lewy body’/ Parkinsonian dementia – where the fluctuating, delirious and psychotic aspects are especially marked. While ECT is sometimes regarded as an antidepressant, it is probably more accurate to think of ECT as having a more general anti-delirium effect.
The take-home message is that much of the clinical pathology associated with dementia is probably not being caused directly by the irreversible dementia, but is instead secondary to the microscopic damage caused by the dementing process, and is a consequence of potentially-reversible delirium.
So the obvious symptoms and behavioural problems of at least some demented patients some of the time may be mostly an acute confusional state, which will sometimes clear away to reveal a much less-severely impaired person.
The measure of how demented a person is, is when that person is at their best, having a ‘good spell’; and all the rest is quite likely due to superimposed, temporary and perhaps reversible delirium.