Psychosis of Alzheimer Disease: A Distinct Syndrome?

1
Psychosis of Alzheimer Disease A Distinct
Syndrome?

• Dilip V. Jeste, M.D.
• University of California, San Diego
• VA San Diego Healthcare System

2
Is Psychosis of Alzheimer Disease an Important
Distinct Syndrome?

• Public health importance
• Differences between AD pt.s with psychosis and
• - AD pt.s without psychosis
• - Non-AD pt.s with psychosis
• Diagnostic entity Diagnostic criteria,
  Neurobiological basis,
• Measurement tools

3
Cumulative Incidence of Psychosis of AD (N 329)
(Paulsen et al., 2000)
4
Psychosis of AD Public Health Importance

• 1) High incidence and prevalence
• 2) Chronic or recurrent
• 3) Commonly produces functional disruption and
  requires
• ongoing treatment

5
Adverse Associations/Consequences of Psychosis of
AD(Differences from AD without Psychosis)

• 1) More agitation, aggression
• 2) More rapid cognitive decline
• 3) Greater caregiver distress
• 4) Earlier institutionalization
• 5) Different treatment considerations
• 6) Higher cost of care

6
Psychosis of AD Evidence for Frontotemporal
Pathology

• 1) Neurobehavioral (Deutsch Paulsen)
• 2) Neuropsychological (Flynn Jeste)
• 3) Brain imaging (Sultzer Forstl Cummings)
• 4) EEG (Lopez Rao)
• Post-mortem (Zubenko
• Mukaetova-Ladinska)

7
Neurotransmitters Putatively Involved in
Psychosis of AD

• Dopamine
• Norepinephrine
• Serotonin
• Acetyl choline

8
Psychosis of AD vs. Schizophrenia in Elderly
Psychosis of AD Schizophrenia
(1) Prevalence 30 to 50 lt1
(2) Bizarre or complex delusions Rare Frequent
(3) Common hallucinations Visual Auditory
9
Psychosis of AD vs. Schizophrenia in Elderly
Psychosis of AD Schizophrenia
(4) First-rank symptoms Rare Frequent
(5) Active suicidality Rare Frequent
(6) Past hx of psychosis Rare Very Common
10
Psychosis of AD vs. Schizophrenia in Elderly
Psychosis of AD Schizophrenia
(7) Eventual remission of psychosis Frequent Rare
(8) Need for years of antipsychotic use Uncommon Very common
(9) Avg. optimal antipsychotic dose 20 of dose in young adults 50 of dose in young adults

11
Psychosis of AD Diagnostic Criteria

• A. Characteristics sxs Delusions or Aud./Vis.
  Hallucinations
• B. Primary dx AD
• C. Chronology of onset of sxs of dementia vs.
  psychosis
• Duration gt1 month
• Severity Functional disruption
• E. Exclusion of Schizophrenia, etc.
  DeliriumOther causes of psychosis
• (Jeste and Finkel, 2000)

12
Psychosis of AD Associated Features

• Agitation
• 2) Negative symptoms
• 3) Depression

13
Assessment of Psychosis of AD

• Specific items from
• a) BEHAVE-AD (Reisberg)
• b) Neuro-Psychiatric Inventory
• or NPI (Cummings)