Marc Holland
Stroke can cause psychosis, a rare complication that can manifest as hallucinations or delusions, disorganized speech, and catatonic or inappropriate motor behaviour. The risk of developing post-stroke psychosis is influenced by various factors, including age, gender, stroke severity, and functional impairments. The pathophysiology of post-stroke psychosis involves damage to specific brain regions, such as the cerebellum, midbrain, basal ganglia, and frontal lobes, which can lead to
| Characteristics | Values |
|---|---|
| Prevalence | 4.86% |
| Onset | Within 1 week after stroke |
| Risk factors | Family history of psychiatric disorders, female, age (70 years), stroke severity, functional impairments, lack of social and family support, unmarried status, fatigue, medical conditions, socioeconomic status |
| Symptoms | Hallucinations, Delusions, disorganized speech, catatonic or inappropriate motor behavior |
| Treatment | Antipsychotic drugs, Neuromodulation, Psychosocial therapy, Psychological intervention |
What You'll Learn
Post-stroke psychosis: how long should we treat?
Post-stroke psychosis is a rare but serious complication of stroke, with an incidence of between 1% and 5.3%. It is associated with higher mortality and poorer functional outcomes. Treatment options are currently limited, and there is a lack of clinical data on the optimal duration of treatment.
Post-stroke psychosis: what are the symptoms?
Post-stroke psychosis can manifest as delusions, hallucinations, and mood changes with psychotic features. Delusions are fixed, false beliefs that are not amenable to change, even in the light of conflicting evidence. Hallucinations are abnormal perceptions that are not experienced by others and can affect any of the senses. Mood changes can include major depressive disorder and bipolar disorder.
Post-stroke psychosis: what causes it?
Post-stroke psychosis is believed to be caused by dysfunction in the subcortical basal ganglia limbic system, involving abnormal dopaminergic neurotransmitters. It is also associated with lesions in the frontal, temporal, and parietal regions of the brain, particularly in the right hemisphere.
Post-stroke psychosis: how is it treated?
Antipsychotic medications are the most common treatment for post-stroke psychosis. However, there is a risk of increased stroke incidence with the use of antipsychotics, especially first-generation antipsychotics. The choice of antipsychotic and the duration of treatment should be carefully considered, as there is a lack of clinical data on the optimal treatment approach for post-stroke psychosis.
Case study: low-dose maintenance therapy for post-stroke psychosis
A case report by Maria do Céu Ferreira et al. describes a 65-year-old man who developed psychotic symptoms, including delusional jealousy and visual illusions, one month after a right posterior cerebral artery ischemic stroke. His symptoms resolved with therapeutic doses of risperidone (3 mg/day). At a 2-year follow-up, the antipsychotic treatment was gradually discontinued over one year. However, one week after stopping risperidone, the patient's symptoms returned, and he was put back on a lower dose of 0.25 mg/day, resulting in rapid clinical remission. The patient's psychotic symptoms remained under control with this low dose of risperidone for one year. This case suggests that low-dose maintenance antipsychotic therapy may be beneficial for certain patients with post-stroke psychosis, especially those with risk factors and non-acute onset.
Post-stroke psychosis is a serious condition that requires careful management. While antipsychotic medications are the current standard of treatment, the optimal duration of treatment is not yet clear. More clinical research is needed to determine the most effective and safe treatment approaches for post-stroke psychosis, including the potential benefits of low-dose maintenance therapy.
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Acute onset of psychosis in older individuals
Psychosis in older individuals is a complex condition that requires careful evaluation and management. The sudden onset of psychotic symptoms in older adults can be a frightening and disorienting experience, and it is essential to address it promptly and effectively. Here are some key considerations and approaches to understanding and managing acute psychosis in older individuals:
Understanding Acute Psychosis in Older Individuals
The development of acute psychosis in older individuals can be attributed to various factors, and it is crucial to differentiate between primary and secondary psychotic disorders. Primary psychotic disorders, such as schizophrenia, major depressive disorder (MDD), and bipolar disorder, have psychotic symptoms as their main clinical presentation. On the other hand, secondary psychotic disorders involve psychosis as a secondary or associated symptom, often resulting from delirium, neurocognitive disorders, substance abuse, or medical/neurological conditions.
The onset of symptoms can provide valuable insights, with acute or subacute onset suggesting delirium or substance-induced psychosis, while insidious onset may indicate a primary psychotic disorder. Additionally, the presence of abnormal findings on physical examinations, visual hallucinations without auditory hallucinations, and the absence of personal or family history of psychiatric disorders can also point towards secondary psychotic disorders.
Management and Treatment Approaches
The management of acute psychosis in older individuals should focus on addressing potentially reversible organic causes, controlling psychotic symptoms, and developing a tailored treatment plan. Here are some key considerations:
- Addressing Underlying Causes: The first step is to identify and address any underlying causes, such as discontinuing offending medications or treating medical or neurological conditions.
- Pharmacological Interventions: Antipsychotic medications are often necessary for symptomatic control, especially when psychotic symptoms impair an individual's ability to receive necessary clinical care or pose a risk of self-harm or harm to others. It is important to start with low doses and gradually increase them, as older adults are more susceptible to adverse effects.
- Non-Pharmacological Approaches: Cognitive behavioural therapy (CBT), verbal de-escalation techniques, family involvement, and environmental modifications can also help manage psychotic symptoms without solely relying on medications.
- Individualized Treatment Plans: Treatment plans should be tailored to each patient's clinical profile, premorbid state, overall goals of care, and social setup. Involving a multidisciplinary team, including medical specialists, nursing staff, and allied health professionals, is crucial for comprehensive care.
- Long-term Management: Long-acting injectable antipsychotics and depot injectable antipsychotics can be considered for long-term management, especially for patients with medication compliance issues.
- Discontinuation Considerations: Antipsychotic medications should be discontinued as soon as clinically feasible to avoid serious adverse effects. Discontinuation may be appropriate when the patient does not respond to treatment, experiences intolerable side effects, or achieves long-standing clinical remission.
The acute onset of psychosis in older individuals is a complex and challenging condition that requires a comprehensive approach. By differentiating between primary and secondary psychotic disorders, addressing underlying causes, and employing a combination of pharmacological and non-pharmacological interventions, healthcare professionals can effectively manage acute psychosis in older adults and improve their overall well-being.
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Post-stroke psychosis: a case report
Post-stroke psychosis is a rare but serious complication of stroke, affecting approximately 4.86% of stroke patients. It is characterised by the presence of hallucinations or delusions, which can have a significant impact on the patient's functioning and quality of life. The onset of psychosis can vary, occurring anywhere from a few days to several months after the stroke. The
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Post-stroke psychosis didn't appear to raise many clinical research concerns
Post-stroke psychosis is a rare complication that occurs in about 4.86% of stroke patients. It is characterised by hallucinations or delusions, which may be accompanied by disorganised speech, catatonic or inappropriate motor behaviour. Post-stroke psychosis is prevalent and disabling, with an increased mortality risk. Patients with post-stroke psychosis are 51% more likely to die within ten years compared to patients with no psychosis after stroke.
There is a lack of clinical research on post-stroke psychosis, and no systematic treatment studies have been conducted. The most common treatment modality for post-stroke psychosis is antipsychotics, which may increase the risk of stroke. However, the efficacy and safety of antipsychotics in the management of post-stroke psychosis have not been tested in interventional clinical studies. More clinical investigations are needed to address the pathology associated with the clinical presentation and explore pharmacotherapies to improve the efficacy and safety of treatment for post-stroke psychosis.
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Antipsychotic drugs appear to have undesirable side effects on glucose and lipid metabolism
A stroke can sometimes lead to hallucinations or delusions, also known as psychotic symptoms, in up to one in 20 people. These symptoms can manifest soon after a stroke or even weeks or months later. While antipsychotic drugs are used to treat psychosis, they can have undesirable side effects on glucose and lipid metabolism.
Antipsychotics have been shown to have serious metabolic side effects on blood glucose levels. A network meta-analysis of 12 antipsychotic drugs used to treat schizophrenia found that only olanzapine was associated with a significant increase in glucose levels compared to a placebo. Olanzapine was also associated with a significantly greater change in glucose levels than ziprasidone, lurasidone, or risperidone.
Additionally, atypical antipsychotics, such as clozapine and olanzapine, have been linked to weight gain and elevated glucose and triglyceride levels. These metabolic side effects compound the risk for coronary artery disease in patients taking these medications. Therefore, routine monitoring of glucose and lipid levels during treatment with antipsychotics is recommended.
Furthermore, both conventional and atypical antipsychotics can indirectly cause obesity, which can lead to insulin resistance and type-2 diabetes. Some atypical agents may also directly induce hyperinsulinemia, followed by weight gain, insulin resistance, and drug-induced diabetes. As a result, guidelines have been developed to manage the adverse metabolic effects of antipsychotics.
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Frequently asked questions
A stroke occurs when the blood supply to the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients. This can result in brain damage and loss of function.
Psychosis is a clinical syndrome that can arise from the alteration of several distinct underlying brain structures and mechanisms. It is characterised by hallucinations or delusions, which may be
