Abid Iraqi

AN UNUSUAL CASE OF NIGHTMARES WITH GALANTAMINE

To the Editor: Galantamine is one of the cholinesterase inhibitors approved by the Food and Drug Administration (FDA) for the treatment of mild to moderate dementia of the Alzheimer’s type. The other cholinesterase inhibitors are tacrine, donepezil, and rivastigmine. The most common adverse events associated with galantamine use are nausea (24%), vomiting (13%), diarrhea (9%), anorexia (9%), dizziness (9%), and weight loss (7%). Other reported side effects are depression (7%), insomnia (5%), and somnolence (4%). Nightmares are reported with donepezil use but have not been reported with galantamine. A case report of nightmares with galantamine use is described.

A case report of paranoid delusion with galantamine use.

min was not dependent on albumin and creatinine levels. In our series, it definitely was associated with intrahospital mortality. Cobalamin has been reported to be an acute phase reactant, which could explain that there are probably confounding factors that might alter the results presented by Salles et al. as well as ours. We therefore think that further research is needed do define the meaning and the implications of high cobalamin levels in the geriatric population.

Impact of Post Discharge Contact by Health Care Team

Funding Sources: The original trial was supported by the Beeson Career Development Award (NIH/NIA grant K23AG040708), NIH/NCATS Colorado CTSA Grant UL1TR001082, and the American Geriatrics Society Jahnigen Career Development Scholars Award. Dr. Blatchford is supported by the Eastern Colorado VA Geriatric Research Education and Clinical Center (GRECC). Contents are the authors’ sole responsibility and do not necessarily represent official NIH or VA views. Author Contributions: There was no primary data or analyses in this letter—the original trial data and analysis was conducted as previously described. Drs. Ginde and Blatchford take full responsibility for the content of this letter. Interpretation of data: Ginde, Blatchford. Drafting of the manuscript: Ginde. Critical revision of the manuscript for important intellectual content: Ginde, Blatchford. Sponsor’s Role: The sponsors had no role in the design, methods, subject recruitment, data collection, analysis, interpretation, or presentation of the study.

Pneumonia Risk with Cholinesterase Inhibitors.

1. Canbaz B, Arik G, Aycicek GS et al. A letter on the Canadian Emergency Department Study J Am Geriatr Soc 2016;64:240–241. 2. Provencher V, Sirois MJ, Ouellet MC et al. Canadian Emergency Team Initiative on Mobility in Aging Decline in activities of daily living after a visit to a Canadian emergency department for minor injuries in independent older adults: Are frail older adults with cognitive impairment at greater risk? J Am Geriatr Soc 2015;63:860–868. 3. Sirois MJ, Emond M, Ouellet MC et al. Cumulative incidence of functional decline after minor injuries in previously independent older Canadian individuals in the emergency department. J Am Geriatr Soc 2013;61:1661– 1668. 4. Lee J, Sirois MJ, Moore L et al. Return to the ED and hospitalisation following minor injuries among older persons treated in the emergency department: Predictors among independent seniors within 6 months. Age Ageing 2015;44:624–629.

VISUAL HALLUCINATION AND TEMAZEPAM: AN UNUSUAL CASE

be. Intellectual dysfunction, such as Alzheimer’s disease, can result in a poor understanding of the inhalation technique, and motor dysfunction, such as rheumatoid arthritis, will directly affect the physical ability to perform the inhalation procedure. It is assumed that, because the ICS therapy was not performed regularly, the improvement in asthma symptoms was limited, which in turn, led to poorer patient compliance. When asthma management is insufficient in spite of repeated inhalation guidance, assisted inhalation may be indicated. For assisted inhalation therapy, it is important to select inhalants that are easy for caregivers to use. Hydrofluoroalkane-BDP is considered appropriate for assisted ICS therapy, because it allows the caregiver to visually check the drug-spraying and inhalation conditions of the patient. In conclusion, assistance by caregivers in ICS therapy is an important therapeutic strategy for elderly patients with asthma, especially those with complications that result in problems with the inhalation technique or compliance, and this strategy can be expected to expand the application of ICS therapy for elderly patients with asthma.

Visual Hallucinations and Parkinsonism in Dementia

To the Editor: We readwith interest the article by Zahirovic et al.1 The article is informative; however, the authors’ suggestion that because the setting was a nursing home for patients with dementia, all of the elderly patients fulfilled the basic dementia criterion and, therefore, the addition of specific signs of dementia with Lewy body (DLB) could indicate a diagnosis of DLB1 may not be correct. For DLB, a patient must have 2 of the 3 core clinical features (parkinsonism, visual hallucinations, cognitive fluctuations) at the time of diagnosis of dementia and not after a lapse of months or years. What the authors found in this study may have been the symptom manifestation of Alzheimer disease (AD) and related dementia, instead of a manifestation of DLB. When patients with known AD and related dementia have psychosis, such as visual hallucinations, they should be classified as having psychosis because of dementia and not DLB. In patients with DLB, visual hallucinations are present early in the course of a dementing illness.2 Furthermore, if a patient has Parkinson disease (PD) symptoms and later on develops visual hallucination, the patient may well have dementia because of PD and not DLB. As outlined by the authors, DLB has a shorter survival.1 Therefore, it is equally important to not over diagnose DLB because of its implication on patient/healthcare proxy decision to forgo lifesustaining measures because of a shorter life expectancy with DLB. In clinical practice, it is known that irrespective of the type of dementia, 3 domains (cognition, functional status, behavioral issue) are affected, and usually the more severe the cognitive difficulty, the more dependent the patient will be for functional assistance, and is at more risk of developing behavioral symptoms (ie, irrespective of the type of dementia with the worsening in dementia, patients are anticipated to have behavioral issues). Delusions and hallucinations are very common in AD and predict cognitive and functional decline with the presence of hallucinations also associated with institutionalization and mortality.3 Furthermore, it is not unusual that with the progression in AD dementia patient may have the manifestation of parkinsonism. The major parkinsonism-plus syndromes include progressive supranuclear palsy, multiple system atrophy, corticobasal degeneration, as well as parkinsonism occurring in the context of AD or one of the other primary dementing disorders.4 The frequency and severity of extrapyramidal signs, a common feature of AD, appear to increase over time with disease severity.5 A differentiation between Parkinson’s Disease dementia (PDD) and DLBneeds to bemade.Dementia is a common feature of PD.6 Cognitive dysfunction is common in PD and exists on a continuum of severity; prevalence increases with the duration of the movement disorder. When severe, dementia often surpasses the motor features of PD as a major cause of disability andmortality.2 In PDD, dementia occurs in the setting of well-established parkinsonism, whereas in DLB, dementia

Effect of Place of Birth on Muslims’ Attitudes Toward Diagnosis Disclosure

ted in the paper in the Discussion section as a study limitation. In this case, performing a sensitivity analysis to determine the potential magnitude of the bias is impossible. Despite these considerations, it should be emphasized that in our report, we do not conclude the causal effect, but only hypothesize the correlation between periodontitis and subsequent dementia. We appreciate Dr. GodardSebillotte and colleagues’ opinions, which certainly enrich our study results. Additional related studies in the future should particularly consider these concerns.