Emergence of psychosis and depression in the longitudinal evaluation of Alzheimer's disease

Neuropsychiatric disturbance in Alzheimer's disease clusters into three groups: the Cache County study

OBJECTIVE

We investigated the frequency and inter-relationship of neuropsychiatric disturbances in a population sample of persons suffering from Alzheimer's disease (AD).

METHOD

Screening 5,092 elderly residents (90% of the population aged 65 and older) of Cache County, Utah, for dementia, we identified 198 persons with AD using a comprehensive neuropsychiatric examination protocol. This examination included the Neuropsychiatric Inventory (NPI), a widely used measure of dementia-associated neuropsychiatric disturbances.

RESULTS

Overall, 60% of individuals with AD reported one or more neuropsychiatric symptoms. A latent class analysis revealed that these participants could be classified into three groups (classes) based on their neuropsychiatric symptom profile. The largest class included cases with no neuropsychiatric symptoms (40%) or with a mono-symptomatic disturbance (19%). A second class (28%) exhibited a predominantly affective syndrome, while a third class (13%) had a psychotic syndrome.

CONCLUSION

Data from this first US population-based study of AD-associated neuropsychiatric disturbances suggest that a significant majority of persons with AD suffer from one or more neuropsychiatric disturbance. Based on phenomenological study, the spectrum of neuropsychiatric symptoms in AD can be empirically classified into three groups: an affective syndrome, a psychotic syndrome and other neuropsychiatric disturbance. The biologic and predictive validity of this classification merits further investigation.

Antipsychotic medications and the elderly: effects on cognition and implications for use

Despite being frequently prescribed in the elderly, antipsychotic medications are commonly associated with adverse effects in this population, including sedative, orthostatic and extrapyramidal adverse effects. Growing evidence suggests that antipsychotics can also cause deleterious cognitive effects in some elderly patients. Preclinical and growing clinical evidence indicates that inhibitory effects on dopaminergic, cholinergic and histaminergic neurochemical systems may account for antipsychotic-associated cognitive impairment in the elderly. A review of published reports of the cognitive effects of antipsychotics in the elderly suggests that newer antipsychotic medications may possess a more favourable cognitive profile than that of traditional agents in this population. The cognitive effect that a specific antipsychotic will have in the elderly, however, is likely better predicted by considering the pharmacodynamic action of an individual agent in combination with the pathophysiology of the condition being treated. Agents with relatively weak dopamine inhibiting effects (e.g. clozapine and quetiapine), for example, would theoretically have a cognitive profile superior to that of agents with higher degrees of dopaminergic inhibition (all traditional agents, risperidone, olanzapine and ziprasidone) when used for conditions associated with diminished dopamine function (e.g. idiopathic Parkinson's disease). Drugs with weak anticholinergic effects (high-potency traditional agents, risperidone, quetiapine and ziprasidone) would theoretically be less likely to cause cognitive impairment than agents with high degrees of cholinergic receptor blocking actions (clozapine and olanzapine) when treating patients with impaired cholinergic function (e.g. Alzheimer's disease). Cholinergic agonist effects of clozapine and olanzapine may, however, mitigate potential adverse cognitive effects associated with the cholinergic blocking actions of these agents. Large, rigorous trials comparing the cognitive effects of antipsychotics with diverse pharmacodynamic actions are lacking in the elderly and are needed.

The progression of cognitive impairment in dementia with Lewy bodies, vascular dementia and Alzheimer's disease

BACKGROUND

Little is known about the rate of progression or associations of cognitive impairment in dementia with Lewy bodies (DLB), or the associations of accelerated decline.

METHOD

Dementia patients from a case register were evaluated at baseline and 1 year follow-up using the Cambridge Assessment for Mental Disorders in the Elderly, section B (CAMCOG) and the Mini-Mental State Examination (MMSE) to determine the rate of cognitive decline. Operationalized clinical diagnoses were applied (NINCDS ADRDA for Alzheimer's disease (AD), NINCDS AIRENS for vascular dementia (VaD) and consensus criteria for DLB).

RESULTS

One hundred and ninety-three patients completed annual MMSE schedules (AD, 101; DLB, 64; VaD, 38), of whom 154 completed the CAMCOG. The magnitude of cognitive decline (MMSE, 4-5 points; CAMCOG, 12-14 points) was similar in each of the dementias. The strongest predictor of accelerated cognitive decline in DLB was the apolipoprotein E4 allele (17.5 vs 8.3 points decline on the CAMCOG).

CONCLUSION

Over 1 year, DLB, VaD and AD patients had similar rates of cognitive decline overall. Apolipoprotein E4 may be an important predictor of more rapid decline in DLB.

Relationship of psychosis to aggression, apathy and function in dementia

BACKGROUND

Psychosis has been associated with aggression in dementia, but the nature of this relationship has been unclear. There has been very little research into the relations between apathy and functional status to psychosis in dementia. The purpose of this study is to investigate the relationship between psychosis and aggression, apathy, and functional status in outpatients with dementia.

METHODS

The presence of psychosis was assessed by clinical interview and two scales: the Neuropsychiatric Inventory and the Columbia University Scale for Psychopathology in Alzheimer's Disease. The maximum likelihood estimation technique was used to determine the best estimate of the presence of psychosis. Aggression, apathy, and functional status (activities of daily living: ADLs) were measured using structured instruments.

RESULTS

Sixty-one subjects were included. The CUSPAD and NPI provided low false positive and negative rates. ANCOVA analyses showed that psychosis was significantly associated with aggression, even when controlling for apathy, depression, and ADLs. Psychosis was related to apathy only when depression was controlled for. Hallucinations were related to impaired basic ADLs, even when depression and apathy were controlled for.

CONCLUSIONS

Relationships were found between psychotic symptoms in dementia and aggression as well as apathy and impaired functional status. These relationships suggest pathophysiologic mechanisms and have possible treatment implications.

Prevalence and pharmacological management of behavioural and psychological symptoms amongst dementia sufferers living in care environments

BACKGROUND

Behavioural and psychological symptoms in dementia (BPSD) are a common reason for placement in long term care and are often associated with indiscriminate prescription of psychotropic medication.

AIMS

To determine the prevalence of BPSD in care environments, their relationship with severity of dementia and the pattern of psychotropic medication.

METHODS

Two hundred and thirty-one elderly residents (39% living in social care facilities and 61% in nursing home care) were assessed using a range of standardised psychiatric schedules. Additional information about the residents and medication was obtained from professional carers.

RESULTS

Overall 90% of residents had dementia, 79% of whom had clinically significant BPSD with 58% receiving psychotropic medication. There was no difference in the prevalence of BPSD between social and nursing care. Depression was most common in people with mild dementia, whilst delusions arose most frequently in those with moderate dementia and aberrant motor behaviour had a high prevalence in people with severe dementia.

CONCLUSION

BPSD are common in elderly people with dementia living in care environments. More rigorous guidelines are needed pertaining to the prescription and monitoring of medication and the need to disseminate skills regarding psychosocial management approaches to care staff.

Aging, mild cognitive impairment, and Alzheimer's disease

Research in the field of aging and dementia is moving forward at a rapid pace, in both basic biology of dementing disorders and clinical investigations. These two approaches to research on aging and dementia need to advance in parallel, such that when work on the pathophysiology of these disorders is translated into therapeutic practice, the appropriately characterized clinical cohorts will be available for therapeutic trials of these treatment strategies.

Neurobehavioral and neuropsychiatric symptoms in Alzheimer's disease: characteristics and treatment

Neuropsychiatric symptoms are common in Alzheimer's disease. Personality changes, mood disturbance, and psychosis are frequently seen and may coexist in the same patient. Neuropsychiatric symptoms may signal the onset of disease and often fluctuate and recur. These symptoms are associated with a more rapid cognitive and functional decline that can lead to institutionalization. Cholinergic therapy, disease-modifying therapy, and psychotropic medications can improve these symptoms.

Hallucinations, delusions, and cognitive decline in Alzheimer's disease

OBJECTIVES

To examine the occurrence of hallucinations and delusions in Alzheimer's disease over a 4 year period and their association with rate of cognitive decline.

METHODS

A cohort of 410 persons with clinically diagnosed Alzheimer's disease underwent annual clinical evaluations over a 4 year period. Participation in follow up exceeded 90% in survivors. Evaluations included structured informant interview, from which the presence or absence of hallucinations and delusions was ascertained, and detailed testing of cognitive function. The primary cognitive outcome measure was a composite cognitive score based on 17 individual performance tests. The mini mental state examination (MMSE) and summary measures of memory, visuoconstruction, repetition, and naming were used in secondary analyses.

RESULTS

At baseline, hallucinations (present in 41%) and delusions (present in 55%) were common and associated with lower cognitive function. In analyses that controlled for baseline level of cognitive function, demographic variables, parkinsonism, and use of antipsychotic medications, hallucinations, but not delusions, were associated with more rapid cognitive decline on each cognitive measure. In the primary model, there was a 47% increase in the average annual rate of decline on a composite cognitive measure in those with baseline hallucinations compared with those without them. This effect was mainly due to a subgroup with both auditory and visual hallucinations.

CONCLUSION

These findings suggest that the presence of hallucinations is selectively associated with more rapid cognitive decline in Alzheimer's disease.

A 2-year follow-up of behavioural and psychological symptoms in Alzheimer's disease

BACKGROUND

The aim was to examine the longitudinal occurrence and persistence of behavioural and psychological symptoms of dementia (BPSD) in Alzheimer's disease (AD).

METHODS

Following 60 patients with mild to severe AD over a period of 2 years with annual evaluations, the prospective occurrence and persistence of BPSD in AD were determined by using the Behavioural Abnormalities in AD Rating scale (BEHAVE-AD). Clinical and demographic features of the AD patients were analysed for their association with course features of these symptoms.

RESULTS

All of the 60 AD patients experienced BPSD at some point during the 2-year period, particularly agitation was present in every patient within this period. 2-year persistence of BPSD in AD was frequently observed in patients with agitation and with depressiveness, with less frequency in patients with anxiety and aggressiveness, but not in patients with delusions or hallucinations. 2-year persistent aggressiveness was associated with older age and more functional impairment. More functional impairment was also related to 2-year non-persistent hallucinations.

CONCLUSIONS

Counselling AD patients and their families and tailoring therapeutic strategies should take into account the different modi of BPSD in AD occurring and persisting longitudinally and interacting with functional disturbances.

Relationship of behavioral and psychological symptoms to cognitive impairment and functional status in Alzheimer's disease

OBJECTIVE

This cross-sectional study examined the relationship of behavioral and psychological symptoms to cognitive and functional impairment in Alzheimer's disease (AD).

DESIGN

One hundred and fourteen patients were evaluated consecutively at a university-affiliated outpatient memory disorders clinic and diagnosed with possible or probable Alzheimer's disease (AD) according to NINCDS-ADRDA criteria. Subjects were assessed with the Behavioral Pathology in Alzheimer's Disease Scale (BEHAVE-AD), Revised Memory and Behavior Problem Checklist (RMBPC), Blessed Dementia Scale (BDS), and Mini-Mental State Examination (MMSE).

RESULTS

Several symptoms of behavioral pathology showed associations with MMSE scores, including activity disturbances, delusions, and hallucinations. After controlling for the variance associated with the MMSE, activity disturbances, diurnal disturbances, delusions, and hallucinations were linked with BDS scores.

CONCLUSIONS

The results suggest that some non-cognitive symptoms may be related to the neurobiologic mechanisms underlying the increased cognitive dysfunction in AD. Specific symptoms of behavioral pathology may also impact a patient's ability to perform important self-maintenance behaviors.

Neuropsychiatric aspects of Alzheimer's disease

The increase in research studies focusing on neuropsychiatric symptoms over the last decade has greatly increased our knowledge base, particularly with regard to the frequency of these symptoms and their impact on both patients and carers. We still have a poor understanding of the natural course of these symptoms and their biologic correlates, however, and more specific treatment studies are needed to inform clinical management.

Prevalence and correlates of Capgras syndrome in Alzheimer's disease

OBJECTIVES

This study examined the prevalence and clinical correlates of Capgras syndrome (CS) in Alzheimer's disease.

DESIGN

Cross-sectional study of elderly patients evaluated at an outpatient memory disorders clinic classified according to the presence or absence of CS.

SUBJECTS

One hundred and fifty-one consecutive patients diagnosed with probable (N=110) or possible (N=48) Alzheimer's disease (AD) utilizing NINCDS-ADRDA diagnostic criteria.

MATERIALS

The Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), Mini-Mental State Examination (MMSE) and Blessed Dementia Scale (BDS).

RESULTS

CS was observed in 10% of the sample (N=16). Associated factors included other delusions, lower MMSE scores and higher BDS scores. The relation between CS and both cognitive and functional status remained significant after controlling for other delusions.

CONCLUSION

CS was prevalent in approximately 10% of our community-dwelling AD sample. This syndrome was more common at the later stages of the illness and showed relations with increased functional impairment and other psychotic symptomatology.

Variables linked to psychotic symptoms in Alzheimer's disease

This study is aimed at assessing the prevalence and features of psychotic symptoms in a sample of 180 patients with Alzheimer's disease (AD). Sixty-four patients (35.5% of the sample) showed one or more psychotic symptoms. The presence of these symptoms correlated with the severity of the patients' cognitive impairment, as well as the patients' age at first assessement. Sex, duration of illness, education and familiar history for dementia were not significantly correlated with the psychotic symptoms. Hallucination was the most common symptom (24.4%, of the whole sample), followed by delusion (18.3%) and misperception (11.1%). Visual hallucinations were more frequent than auditory, and, among delusions, persecutory and theft themes were largely prevailing. Misperceptions included television related phenomena and phantom boarder illusions. A follow-up study of 37 patients demonstrated the association between the presence of psychotic symptoms and a steeper slope of cognitive deterioration. Copyright 1998 Lippincott Williams & Wilkins

Prevalence and clinical correlates of psychotic symptoms in Alzheimer's disease

Psychotic symptoms occur commonly in Alzheimer's disease (AD), predict a more rapid rate of cognitive decline and increase the risk of aggressive behaviour. Seventy patients with probable AD, recruited from an old age psychiatry service, were assessed to determine the prevalence and clinical correlates of delusions and hallucinations. Psychiatric symptoms were measured using the Behavioural Pathology in Alzheimer's Disease Rating Scale (BEHAVE-AD), Hamilton Rating Scale for depression (HRSD) and the Depressive Signs Scale (DSS). Thirty-four per cent of the sample experienced delusions and 11% hallucinations in the previous month. Men were more likely than women to have experienced psychotic symptoms. Psychotic and non-psychotic groups did not differ in age, age at illness onset, dementia severity, HRSD or DSS scores. This study confirms the high prevalence of psychotic symptoms in AD patients encountered in clinical practice, and suggests that psychosis and depression represent independent behavioural disturbances in AD.

Factors associated with psychotic symptoms in Alzheimer's disease

OBJECTIVES

Many clinical and biological factors have been reported to be associated with the presence of psychosis in patients with Alzheimer's disease, although the associations were variable. The aim of this study was to clarify factors associated with the presence of psychosis in patients with Alzheimer's disease.

METHODS

Psychiatric functioning was studied in 228 patients with Alzheimer's disease based on the results of the behavioural pathology in Alzheimer's disease rating scale or the neuropsychiatric inventory. The effects of sex, education level, age, duration of illness, cognitive function, and apolipoprotein E genotype were investigated for dichotomous psychotic status with a multiple logistic regression analysis.

RESULTS

Of the 228 patients with Alzheimer's disease, 118 (51.8%) showed evidence of delusions or hallucinations. Of these, 94 had delusions only, three had hallucinations only, and 21 had both. Older age, female sex, longer duration of illness, and more severe cognitive impairment were the factors independently associated with the presence of psychosis. The presence of psychosis was not significantly related to either educational level or apolipoprotein E genotype.

CONCLUSIONS

Age, sex, and severity of illness were independent factors associated with the presence of psychosis in patients with Alzheimer's disease. The reason why some patients with Alzheimer's disease develop psychosis remains unclear. There may be distinctive subtypes of Alzheimer's disease or the presence of individual factors which affect the development of psychosis.

Therapeutic targets in late-life psychoses: review of concepts and critical issues

Psychoses in late life are a diagnostic challenge because of disagreement over how these entities should be classified. The main diagnostic categories of late-life psychoses include dementia with psychotic symptoms, late-onset schizophrenia, delusional disorder, early-onset psychotic disorders extending through late life, late-onset mood disorders, psychotic disorders caused by medical conditions or medications, and delirium. First onset of psychotic symptoms in late life is commonly associated with identifiable structural brain abnormalities and reflects underlying brain pathology. We reviewed the available literature on late-life psychotic manifestations, focusing on diagnostic classification and treatment approaches. Antipsychotics are the mainstay of treatment for these conditions, but should be used cautiously in elderly patients because of their increased sensitivity to side effects. Overall, appropriate research data on the effectiveness of various antipsychotic agents for late-life psychotic conditions are lacking. Non-antipsychotic psychotropic medications may be of value in managing some of these conditions.

A prospective study of psychotic symptoms in dementia sufferers: psychosis in dementia

Eighty-seven out of a clinical cohort of 124 patients with Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.) dementia were followed up at monthly intervals for 1 year. Psychotic symptoms were assessed using the Burns's Symptom Checklist, and cognitive functioning was evaluated with the CAMCOG. The annual incidence rate of psychotic symptoms was 47%, although many of the incident symptoms lasted less than 3 months. Fifty-three percent of patients with psychosis experienced resolution of their symptoms. Patients either experienced brief or persistent psychotic disorders, with few having an intermediary course. Persistent psychosis was significantly associated with a 3-month duration of symptoms at baseline. Neuroleptics did not significantly influence the course of psychotic symptoms.

Age and psychosis in degenerative dementia

Among psychiatric inpatients with primary degenerative dementia, those with psychotic symptoms (N = 20) were older than those without (N = 20) (t = 3.48; p < 0.001). Persecutory delusions were the most frequent psychotic phenomena. Duration of dementia overlapped, but scores on the Global Deterioration Scale and the Cornell Scale for Depression in Dementia were lower in the psychotic group after correcting for age. The limited literature concerning demographic and clinical correlates of psychosis in dementia is reviewed; the age difference noted is consistent with two other reports.

Diagnosis of Alzheimer's disease. Report of an International Psychogeriatric Association Special Meeting Work Group under the cosponsorship of Alzheimer's Disease International, the European Federation of Neurological Societies, the World Health Organization, and the World Psychiatric Association

Current knowledge with respect to the diagnosis of Alzheimer's disease (AD) is reviewed. There is agreement that AD is a characteristic clinicopathologic entity that is amenable to diagnosis. The diagnosis of AD should no longer be considered one of exclusion. Rather, the diagnostic process is one of recognition of the characteristic features of AD and of conditions that can have an impact on presentation or mimic aspects of the clinicopathologic picture. The present availability of improved prognosis, management, and treatment strategies makes the proper, and state-of-the-art, diagnosis of AD a clinical imperative in all medical settings. Concurrently, information regarding the relevance and applicability of current diagnostic procedures in diverse cultural settings must continue to accrue.

Association of the APOE epsilon 4 allele with clinical subtypes of late life depression

The APOE genotypes of 45 elderly inpatients with major depression were determined to investigate the relationship of this disorder to irreversible dementia in late life. We specifically tested the hypothesis that the frequency of the APOE epsilon 4 allele is elevated in depressed elders with cognitive impairment or psychotic features, subtypes that have been reported to be at increased risk of developing Alzheimer's disease (AD). The frequency of epsilon 4 allele was not elevated in the overall group of 45 inpatients and, contrary to our expectation, was not associated with cognitive impairment in this group. In contrast, the epsilon 4 allele frequency for the patients with psychotic features was nearly four times that for the patients without psychotic features and nearly double that of elderly controls. These data suggest that elderly depressed inpatients with cognitive impairment are at risk for developing AD by an epsilon 4-independent pathway, while those with psychotic features are at risk for developing AD by an epsilon 4-dependent pathway. These findings suggest that subtypes of idiopathic major depression in late life may serve as landmarks that distinguish separable pathogenetic pathways to AD.

Manchester and Oxford Universities Scale for the Psychopathological Assessment of Dementia (MOUSEPAD)

BACKGROUND

There is increasing awareness of the importance of psychopathological and behavioural changes in dementia and a need for an instrument to measure these features which achieves an appropriate compromise between brevity and breadth. We describe a newly developed 59-item instrument: the MOUSEPAD.

METHOD

Reliability, sensitivity and validity were examined with 30 carers, each of whom was interviewed four times over six weeks.

RESULTS

For different symptom groups, kappa ranged from 0.43 to 0.93 for test-retest reliability, from 0.56 to 1.0 for inter-rater reliability, and from 0.43 to 0.67 for the validation study.

CONCLUSIONS

The scale may be useful as an outcome measure in drug trials, for correlating psychopathological and behavioural changes with post-mortem findings, and in epidemiological surveys.

Cortical glucose metabolism in psychiatric wandering patients with vascular dementia

The cerebral metabolic rate for glucose (CMRglc) in 18 patients with vascular dementia (VD) and 15 age-matched normal subjects was measured with positron emission tomography (PET) and the 18F-fluorodeoxyglucose technique. Nine of the 18 VD patients manifested abnormal wandering behavior with some psychiatric symptoms: they showed relatively spared CMRglc, which was higher than that of nonwandering patients, especially in the bilateral frontal lobes, left parietal lobe, left temporo-parieto-occipital region, left occipital lobe, and cerebellum. The results suggest that psychiatric wandering behavior of patients with VD could be correlated with partial sparing of CMRglc in the regions listed above.

Psychotic symptoms in Parkinson's disease patients with dementia

OBJECTIVE

To assess the prevalence of psychotic symptoms in a group of patients with Parkinson's disease (PD) and dementia and examine the association of psychotic symptoms with neuropsychiatric problems, the level of distress reported by caregivers, and cognitive and functional impairment.

DESIGN

The psychotic and nonpsychotic patients with PD dementia were compared on a series of demographic, neuropsychiatric, behavioral, caregiver complaint, and cognitive measures.

SETTING

The database from nine university-based State of California Alzheimer's Disease Diagnostic and Treatment Centers (ADDTCs).

PARTICIPANTS

101 patients diagnosed with PD.

RESULTS

A total of 36 of the 101 patients (35.6%) had either hallucinations, delusions, or both. The psychotic patients had significantly more insomnia, confusion, agitation, personality changes, and self-care problems and were noted by their caregivers to be significantly more unmanageable at home than their nonpsychotic counterparts. On cognitive scales, psychotic patients were significantly more impaired.

CONCLUSION

Many patients with PD and dementia experience psychosis. Psychotic symptoms in PD dementia patients are associated with major behavioral, cognitive, and functional problems.

Clinical experiences and methodologic challenges in conducting clinical trials on the behavioral disturbances of dementia

With a world population increasing in size and age, the number of elderly people with behavioral disturbances in dementia (BDD) is becoming an increasing problem. The burden of caring for someone with BDD may be so great that it leads to premature institutionalization of the patient. Few clinical trials have focused on noncognitive behavioral symptoms in this group of elderly patients, and little is known about the efficacy of drugs against these symptoms. The pharmaceutical companies have recently begun to assess different medications, but clinical trials in the elderly present a variety of problems not encountered in other patient populations. This article describes how the administration, initiation, logistics, finances, and methodology of such trials must be carefully assessed. Consideration of these factors together with improved definitions of behavioral symptoms and the advances in medication in this area should lead to an improvement in the treatment and management of behavioral disorders in the elderly.

Neuroleptic treatment of agitation and psychosis in dementia

Neuroleptics remain the mainstay for the treatment of behavioral disturbance and psychotic symptoms in demented patients. The limited available data suggest that low-dose neuroleptics are significantly more efficacious than placebo, though the magnitude of the effect is moderate in most published studies. Demented patients are particularly prone to neuroleptic side effects, and individualized dose titration may be necessary to achieve the optimal trade-off between efficacy and side effects. Target behavioral symptoms and side effects, including effects on cognition and activities of daily life, should be identified and assessed serially during neuroleptic treatment. The choice of neuroleptic depends more on likely side effects than differential efficacy, and non-response or intolerable side effects should lead to dose adjustment or a switch to an alternative class of neuroleptic (or an alternative type of medication). Further studies of optimal neuroleptic dosage, the optimal duration of continuation neuroleptic treatment, and placebo-controlled studies comparing neuroleptics to other classes of medications are needed.

Biologic markers and neurochemical correlates of agitation and psychosis in dementia

Behavioral and psychiatric symptoms frequently accompany the cognitive deterioration of dementia occurring in up to 80% of both community-based and nursing home patients. In Alzheimer's disease (AD), behavioral complications may develop at any stage of the disease process and tend to follow a more unpredictable course than the core cognitive symptoms. Over the past 15 years, our knowledge of the biologic and neurochemical basis of dementia, and of AD in particular, has increased significantly. Great emphasis has been placed on the cholinergic system abnormalities in the context of the cognitive impairment in AD and on the psychopharmalogic enhancement of cholinergic transmission in AD. However deficits in other neurotransmitter systems, such as the noradrenergic, serotonergic, and dopaminergic systems, also occur and may contribute to the core cognitive symptoms of AD. More recently, there has been increased interest in the biologic and neurochemical basis of behavioral and psychiatric disturbances in dementia. This article reviews the evidence for biologic and neurochemical correlates of psychosis and agitation in dementia, and discusses the treatment implications for these findings.

Delusions and dementia: clinical and CT correlates

INTRODUCTION

Delusions occur frequently during the course of Alzheimer's disease (AD) and multi-infarct dementia (MID). Their clinical significance and their relationship with progression of disease and involvement of selected cerebral areas are still unclear. The aim of the study was to determine the clinical and CT correlates of delusions in patients with dementia.

MATERIAL AND METHODS

A series of 67 probable AD and 32 MID patients, underwent computed tomographic scans, psychometric tests, neurologic and psychiatric examination, and blood and serum tests.

RESULTS

Twenty-four patients were found to have delusions during the clinical evaluation. Delusional patients showed a significantly higher age when compared with non-delusional patients. The results of a multiple logistic regression (with stepwise deletion of the redundant variables) of the CT lesions on the presence of delusions, showed that only the presence of isolated white matter lesions in the frontal lobes were significantly related to the occurrence of delusions (Exp B = 3.42; Beta = 1.2; S.E. = 0.6; Sig T = 0.04). Frontal white matter changes were significantly related to delusions when a multiple regression analysis, entering age and total number of lesions at CT scans, was carried out.

CONCLUSIONS

We found that focal lesions in the frontal areas were the only variable that appeared to be significantly and independently associated with delusional disorders.

Loss of dopamine D2 receptors varies along the rostrocaudal axis of the hippocampal complex in Alzheimer's disease

The anatomy of the hippocampus, including the organization of its intrinsic neural circuits and afferents, is organized along a rostrocaudal axis. Dopamine D2 receptors are expressed in specific regions of the hippocampal complex (hippocampal subfields, entorhinal cortex, perirhinal cortex) and show differential expression along this axis. The dentate gyrus and CA3/CA4 subfields show higher numbers of D2 receptors in the rostral than in the caudal levels. In contrast, the subiculum shows the reverse gradient. We report here that Alzheimer's disease (AD) is associated with reduced expression of the dopamine D2 receptor, but the effects differ with respect to the rostrocaudal axis and area within the hippocampal complex. The number of D2 receptors is significantly reduced in the molecular layer of the dentate gyrus, CA3 subfield, and subiculum. For the dentate gyrus and subiculum, there were greater losses at more rostral levels. The CA3/CA4 subfields showed the greatest losses caudally. The entorhinal cortex, which shows only modest expression of D2 receptors in controls, does not exhibit reduced numbers in AD. The external laminae of the rostral perirhinal cortex showed more significant losses than more caudally in this cortical field. The regions showing loss of D2 receptors do not typically contain neuritic plaques, neurofibrillary tangles, or significant neuron loss. Thus other mechanisms must account for the unique gradient of D2 receptor loss in the hippocampus. The regions of reduced expression of dopamine D2 receptors do correlate well with the terminal zone of the dentate association pathway, the afferents from the amygdala and perirhinal cortex, and the sources of those afferents within the amygdala and perirhinal cortex. The specific patterns of reduced D2 receptor expression in AD are likely to contribute significantly to the disrupted information flow into and out of the hippocampus and, thus, of functions subserved by this system.

The clinical diagnosis and misdiagnosis of senile dementia of Lewy body type (SDLT)

BACKGROUND

Current clinical classifications do not contain specific diagnostic categories for patients with senile dementia of the Lewy body type (SDLT), recently proposed as the second commonest neuropathological cause of dementia in the elderly. This study determines how existing clinical diagnosis systems label SDLT patients and suggests how such patients may be identified.

METHOD

A range of clinical diagnostic criteria for dementia were applied to case notes of autopsy-confirmed SDLT (n = 20), dementia of Alzheimer type (DAT; n = 21) and multi-infarct dementia (MID; n = 9) patients who had received psychogeriatric assessment. The predictive validity of each set of clinical criteria was calculated against the external criterion of neuropathological diagnosis.

RESULTS

Many SDLT patients erroneously met criteria for MID (35% with Hachinski scores > or = 7) or for DAT (15% by NINCDS 'probable AD', 35% by DSM-III-R DAT and 50% by NINCDS 'possible AD'). Up to 85% of SDLT cases could be correctly identified using recently published specific criteria.

CONCLUSIONS

SDLT usually has a discernible clinical syndrome and existing clinical classifications may need revision to diagnose correctly such patients.

Neuropathological correlates of psychotic phenomena in confirmed Alzheimer's disease

BACKGROUND

The prevalence of psychotic phenomena in confirmed Alzheimer's disease (AD) and their potential neuropathological correlates have rarely been the subject of prospective investigation.

METHOD

Psychopathological disturbances were recorded prospectively according to the Geriatric Mental State Schedule and the CAMDEX: The frequency of these phenomena and neuropathological changes were examined in 56 patients with definite AD.

RESULTS

Hallucinations had been documented in 13 patients, paranoid delusions in 9 and delusional misidentification (e.g. the Capgras-type and the 'phantom boarder' symptoms) in 14 patients. Misidentifications were associated with lower neurone counts in the area CA1 of the hippocampus. Delusions and hallucinations were observed in patients with less severe cell loss in the parahippocampal gyrus and with lower cell counts in the dorsal raphe nucleus. A decrease of neurones in the locus coeruleus in a subset of depressed patients with AD had been reported earlier. Delusions and delusional misidentification were common in 5 patients with basal ganglia mineralisation, but there was no statistically significant association of these symptoms with the presence of Lewy bodies in the brainstem and neocortex of our patient sample.

CONCLUSIONS

These findings are compatible with the view that morphological changes in certain brain areas may promote the development of psychotic phenomena in AD. AD may offer a model for the understanding of pathomechanisms underlying the development of psychopathological disturbances in other psychoses with more discrete neuropathological changes.

The management of other psychiatric states. Hallucinations, delusions, and other disturbances

The behavioral disturbances that are most common in Alzheimer's disease are not those directly associated with the core characteristics of the disease; however, they often cause the most difficult problems of management. These disturbances include agitation, hallucinations, and delusions. This article reviews their prevalence, etiology, differential diagnosis, and management.

A Study of Delusions in a Large Cohort of Alzheimer's Disease Patients

The authors analyzed data on delusions and associated neuropsychiatric symptoms in 1,229 consecutive patients with Alzheimer's disease (AD) at nine university-based State of California Alzheimer's Disease Diagnostic and Treatment Centers. Thirty-four percent of these patients had delusions. The delusional patients were older, more likely to be female, and had a later onset of AD than the nondelusional group. Compared to the nondelusional patients, the delusional patients also had more severe global cognitive impairment, along with a higher prevalence of hallucinations, agitation, depression, and gait disturbance, as well as family and marital difficulties and self-care problems.

Sodium valproate in the treatment of behavioral disturbance in dementia

Management of the behavioral complications of dementia, including agitation and aggression, presents a tremendous challenge to families and caregivers of afflicted patients. Most previous pharmacotherapies have shown minimal efficacy and significant side effects. We report our initial, open-label experience using the anticonvulsant sodium valproate in four dementia patients with severe behavioral disturbance. The drug was well tolerated by all patients, with no side effects or laboratory abnormalities, during 1- to 3-month trials. Two patients showed significant improvement in behavior, and a third had a transient response. Valproate may be a useful agent in the treatment of behavioral disturbance in dementia; controlled trials are needed to document its efficacy.

Effects of a history of heavy alcohol consumption on Alzheimer's disease

Neuropsychological and psychiatric evaluations were made of 39 subjects with possible Alzheimer's disease and a history of excessive alcohol consumption (AD + ETOH), who had been abstinent or had drunk minimally for at least three months before evaluation, and 225 patients with probable Alzheimer's disease (PAD) of comparable age, years of education, and baseline global impairment. At baseline, there were no significant differences between the groups in terms of age of onset of dementia, neuropsychological test scores, or current behavioural or psychiatric symptoms. One year later, no differences in rates of decline between 20 abstinent AD + ETOH patients and 88 PAD subjects could be shown. Thus, past heavy alcohol consumption does not appear to modify the presentation of dementia of the Alzheimer's type, nor does it modify progression over a one-year interval.

Delusions in Alzheimer's disease and multi-infarct dementia

Neuropsychiatric symptoms such as delusions and misidentifications have been reported in dementia ranging from 10% to 73% in Alzheimer's disease (AD) patients and up to 40% in multi-infarct dementia (MID) patients. The aim of this study was to investigate in 61 AD and 31 MID patients both the frequency and the content of delusions during the course of illness and to evaluate the relationship between these and both functional and mental decline. The results indicated that delusion experiences had occurred in 45% of AD patients and in 38% of MID patients, occurring most frequently during the first year of illness. Patients who experienced psychiatric symptoms showed higher mini mental state examination scores and were less impaired in functional disability measures. With regard to the content, no significant differences were observed between AD and MID patients; 53% of psychotic symptoms were found to be paranoid delusions while 47% were misidentification delusions.

Psychotic features and the course of Alzheimer's disease: relationship to cognitive, electroencephalographic and computerized tomography findings

Thirty-one of 50 patients satisfying the NINCDS-ADRDA criteria of probable or possible Alzheimer's disease showed psychotic features during a 2-year observation period. Paranoid delusions were reported in 23 patients, delusional misidentification in 17, visual hallucinations in 16 and auditory hallucinations in 8. All of the 7 patients who died within the observation period had suffered from psychotic features even before the preterminal phase of illness. A faster progression of illness towards more severe stages of dementia was associated with paranoid delusions and hallucinations but not with delusional misidentification. We could not prove a significant influence of age, age of onset, cognitive performance, ventricular enlargement or the severity of quantitative electroencephalographic changes at initial examination on the course of illness. This may indicate that specific psychotic features and their potential organic substrate exert an effect on the progression of illness and on survival in Alzheimer's disease, which is not related to gross brain atrophy and generalized neurophysiological changes.

Clinical features distinguishing large cohorts with possible AD, probable AD, and mixed dementia

OBJECTIVE

To determine whether clinical features and rate of cognitive and functional decline differed in cohorts of possible AD (poAD), probable AD (prAD), and mixed dementia (MIX) patients.

DESIGN

Cohort study with 1-year follow-up examination, comparing three groups of subjects.

SETTING

Outpatient evaluation at nine California Alzheimer's Disease Diagnostic and Treatment Centers (ADDTC).

PATIENTS

There were 1701 elderly patients who presented for evaluation of memory complaints.

MEASUREMENTS

Historical, physical, and neurological variables for cross-sectional comparisons and 1-year rate of change on the Mini-Mental State Examination (MMSE), Blessed Information-Memory-Concentration test (BIMC), and Blessed Dementia Scale (BDS).

RESULTS

Mean initial MMSE scores for poAD (n = 279), prAD (n = 928) and MIX (n = 430) were 17.9 (+/- 7.4), 13.9 (+/- 7.5), and 15.4 (+/- 7.1). Delusions and psychosis occurred in about one-third of each group, most often in those with moderate dementia (MMSE 11-20). PoAD were distinguished from prAD by significantly more alcohol abuse, physical health problems, and focal motor or sensory findings. MIX differed from AD alone by increased prevalence of cardiovascular disease, hypertension, stroke, TIA, and exposure to general anesthesia, and by a greater frequency on exam of depressed mood, focal motor or sensory findings, and gait disorder. All groups declined by about 2.8 points on the BIMC, 2.9 points on the MMSE, and 1.8 points on the BDS, a functional scale, over 1 year. Neither extrapyramidal signs nor psychosis predicted a more rapid rate of decline.

CONCLUSIONS

Various features help to distinguish poAD, prAD, and MIX in a large cohort of patients, but do not predict the rate of progression.

Risk factors for stroke as predictors of platelet membrane fluidity in Alzheimer's disease

We have previously reported that increased platelet membrane fluidity identifies a subgroup of patients with Alzheimer's disease who have distinct clinical features including an earlier age of symptomatic onset, a more rapidly progressive cognitive decline, and a decreased prevalence of focal electroencephalographic findings. In the current study, these patients also exhibited a decreased prevalence of risk factors for stroke compared with patients who had normal platelet membrane fluidity. Our findings suggest that the platelet membrane abnormality describes a clinical subgroup of patients with Alzheimer's disease who are less likely to have coexisting cerebrovascular disease than the remaining patients who meet clinical consensus criteria for probable Alzheimer's disease.