Psychosis of AD is a serious problem for caregivers and often results in institutionalization of the patient (Jeste and Finkel, 2000). Although estimates of the prevalence of psychotic symptoms in dementia vary, approximately 50% of patients experience delusions or hallucinations within the first three years after a clinical diagnosis of AD is made (Paulsen et al., 2000). The usual symptoms of psychosis of AD are simple paranoid delusions of stealing or hiding things, jealousy, or infidelity on the part of the spouse. Visual hallucinations are more frequent than auditory ones (Jeste and Finkel, 2000). Psychosis is more likely to present during intermediate stages of dementia than in very early or very late stages. Psychotic symptoms are rarely the initial manifestation of AD. As the severity of dementia increases, psychotic symptoms improve--it is unclear if this is true remission or merely a result of worsening cognition and speech making it difficult for the patient to express their delusions.
The optimal treatment of psychosis in AD may include pharmacotherapy and/or psychosocial interventions. Pharmacotherapy is necessary when the psychotic symptoms are severe enough to cause distressing agitation or aggression or otherwise disrupt the patient's functioning. The doses of antipsychotics should be considerably lower in patients with dementia than in those with schizophrenia, as can be seen in Table 2 (Jeste et al., 1999b). Psychosocial approaches to treatment emphasize caregiver education and environmental modifications to increase patients' orientation and decrease confusion. Such interventions may include optimization of social contact, increase in structured activities, environmental enrichment, prevention of overstimulation and light therapy (Cohen-Mansfield, 2001).Treatment Considerations
Antipsychotic medications usually constitute the primary pharmacotherapy for psychotic disorders (Jeste et al., 1999b). Guidelines for the dosing of antipsychotic medications are presented in Table 2. In older people, the heightened risk of sedation, postural hypotension, anticholinergic side effects, extrapyramidal symptoms and, especially, tardive dyskinesia makes conventional antipsychotic medications less suitable in most cases. The atypical antipsychotics should usually be considered the first-line treatments because of their greater safety. Nonetheless, even with these medications, sedation, hypotension, weight gain, diabetes and cardiac conduction changes are causes for concerns. For older patients with schizophrenia or psychosis of AD, risperidone(Drug information on risperidone) (Risperdal), olanzapine(Drug information on olanzapine) (Zyprexa) and quetiapine (Seroquel) are currently the three most frequently prescribed antipsychotics. Studies of ziprasidone (Geodon) in this population have not yet been published. Aripiprazole(Drug information on aripiprazole) (Abilify) has recently been approved as an antipsychotic by the U.S. Food and Drug Administration.
Psychosocial treatments are essential for older people with psychoses. As mentioned previously, some nonpharmacologic interventions have empirical support for efficacy in psychosis of AD. For older patients with schizophrenia, a number of different individual and group therapies are beginning to be studied. In our center, we have focused on the following interventions (Granholm et al., 2002):
- Cognitive-behavioral social skills training to target delusional thinking, social skills and coping strategies;
- Medication adherence therapy to provide education and medication management skills to promote adherence to antipsychotic medication regimens;
- Functional adaptation skills training, a group training program that teaches everyday living skills (e.g., financial management, use of transportation);
- Work rehabilitation, using a supported employment model.
There is still much work to be done in terms of optimizing treatment of psychotic symptoms while reducing side effects, increasing optimal health behaviors (e.g., medication adherence, smoking cessation, nutrition and exercise) and minimizing disparities in access to health care for older patients with psychoses. However, there are many reasons to be optimistic about future therapies for older patients with psychoses, as the numbers of clinicians and researchers in the field of geriatric psychiatry continue to grow.