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In everyday practice, psychiatrists serve as members of medical teams in providing treatment to patients who have delirium, dementia, or other cognitive disorders. Psychiatrists often see these patients in hospitals, nursing homes, and other institutional settings. A psychiatrist usually acts as a consultant to a primary care physician or to a hospital service. Psychiatrists help primary care physicians understand the degree to which medical illness contributes to psychiatric symptoms or confusion. Proper treatment of the medical problem may lead to substantial improvement in psychiatric or neurobehavioral symptoms. Psychotropic medication may be helpful in the management of the patient's illness. Psychiatrists must consider medical diagnoses, treatments, drug interactions, and side effects when they prescribe psychotropics as part of their role on the medical team.

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Patients who have cognitive disorders are often unable to give a reliable history, and the history obtained from third parties usually does not totally reveal the diagnosis. The psychiatrist must rely heavily on data obtained from the physical examination and from laboratory tests, electroencephalogram (EEG) findings, and brain imaging. The medical model provides the most appropriate understanding of patient care in cases of delirium and dementia because the medical model stresses a biological etiology for the patient's symptoms. This approach helps the physician establish crucial links between the patient's medical pathology and the neurobehavioral or psychiatric symptoms. Once links have been established, the psychiatrist can recommend drug therapy and psychotherapy integrated in a comprehensive medical treatment plan.

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Patients with delirium and the behavioral complications of dementia often require complicated therapeutic regimens. In some older patients, treatment is not well tolerated and may produce cognitive changes. This is particularly true when patients are receiving treatment for medical disorders. The clinician should understand the behavioral side effects of medical therapies. Removing drugs that produce confusion can help reestablish cognitive function.

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Psychiatrists may attempt to treat agitation or hallucinations by adding psychotropics, but these drugs may worsen the patient's condition. Psychiatrists must be prepared to analyze the possibility of multiple drug interactions before launching into psychopharmacotherapy.

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Physicians who treat cognitive disorders need to cross the traditional boundaries between psychiatry and neurology. More often than not, older patients have multiple disorders. Delirium, dementia, and affective disorder often coexist. The psychiatrist should not only treat depression and other correctable disorders, but also determine the existence of dementia and establish a prognosis, in order to plan appropriate treatment.

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The physician must educate the patient and the family about the nature of the specific illness and the rationale for treatment. Disease processes that cause cognitive deficits may be very complex. Families are often exceedingly anxious because they anticipate the need to accept change in a meaningful relationship. They demand answers. Serious social and financial hardships add to a sense of dread about the future. Most families benefit from a thorough explanation of the patient's condition. Ultimately, the physician must be prepared to explain the contribution made ...

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