Alzheimer disease (AD) is one of the major causes of neurocognitive dysfunction. It has an insidious onset, with gradual progression of cognitive and behavioral symptoms, and is associated with behavioral and psychological symptoms of dementia. Symptoms of AD psychosis include delusions and hallucinations, agitation, aggression, and depression. Studies show that AD psychosis may be a distinct clinical entity with poor outcomes.1 Although the etiology of AD psychosis is not clear, genetic association studies posit a link between psychosis and the absence of APOE*4 alleles.2 Jeste and Finkel3 suggest diagnostic criteria for AD psychosis, including:
• Delusions and/or hallucinations (auditory or visual) that have been present for 1 month or longer
• Symptoms not continuously present before the onset of dementia
In a meta-analysis, the median prevalence of psychotic symptoms (delusions or hallucinations) in patients with AD was 41.1%.4 The median prevalence of delusions was 36%: delusions of theft were the most common. Visual hallucinations were more prevalent than auditory hallucinations (median, 18.7% and 9.2%, respectively). A higher prevalence of psychotic symptoms tended to occur in inpatient settings than in outpatient settings.
In a cross-sectional study, the prevalence of AD psychosis by specific criteria was 7.3%, with a cumulative incidence of 10.6% at 12 months.1 After 1 year, psychotic symptoms persisted in 68.7% of patients with an initial AD psychosis. Symptoms of agitation, aggression, and wandering have also been seen in at least 75% of patients with AD.5
AD psychosis defines a phenotype with greater severity; patients with AD psychosis scored lower in the Cambridge Cognitive Examination and Mini-Mental State Examination and higher on the Rapid Disability Rating Scale-2 and Zarit Burden Interview.1 Moreover, AD psychosis leads to faster functional impairment and increased mortality risk.
Various measures have been developed to assess psychosis and behavioral symptoms objectively. These include the Neuropsychiatric Inventory (NPI), the Consortium to Establish a Registry for Alzheimer Disease-Behavior Rating Scale for Dementia, and the Behavioral Pathology in Alzheimer Disease Scale. The Cornell Scale for Depression in Dementia and the Dementia Mood Assessment Scale are commonly used to measure depressive symptoms, and the Cohen-Mansfield Agitation Inventory assesses symptoms of agitation.
Treatment of elderly patients with dementia and behavioral disturbances is complicated by a multitude of factors, including:
• Age-related pharmacokinetic and pharmacodynamic changes
• Comorbidities and concurrent use of medications
• Safety and efficacy issues of pharmacological treatments, such as FDA black box warnings and limited efficacy
• Cost factors and lack of studies with adequate control group and duration of exposure for nonpharmacological interventions
• Regulatory issues for institutionalized patients
Management of AD psychosis consists of both nonpharmacological and pharmacological interventions (Algorithm). Left untreated, symptoms may be significant enough to present a danger to self or others. This may be due to agitation: yelling, lashing out against others when feeling threatened, or general aggression. Patients may refuse care because of paranoia, wander into unsafe situations, or have agitation resulting in injury (eg, falls).
Dr Madhusoodanan is Clinical Professor of Psychiatry at SUNY Downstate Medical Center in Brooklyn, NY, and Associate Chair in the department of psychiatry at St John’s Episcopal Hospital in Far Rockaway, NY. Dr Ting is PGY-3 Resident in the department of psychiatry at St John’s Episcopal Hospital. The authors report no conflicts of interest concerning the subject matter of this article.
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