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Accelerated atrophy in dopaminergic targets and medial temporo-parietal regions precedes the onset of delusions in patients with Alzheimer's disease. Eur Arch Psychiatry Clin Neurosci 2023; 273:229-241. [PMID: 35554669 PMCID: PMC9958148 DOI: 10.1007/s00406-022-01417-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/11/2022] [Indexed: 12/21/2022]
Abstract
People with Alzheimer's disease (AD) and delusions have worse quality of life and prognosis. However, early markers of delusions have not been identified yet. The present study investigated whether there are any detectable differences in grey matter (GM) volume and cognitive changes in the year before symptom onset between patients with AD who did and did not develop delusions. Two matched samples of AD patients, 63 who did (PT-D) and 63 who did not develop delusions (PT-ND) over 1 year, were identified from the Alzheimer's Disease Neuroimaging Initiative database. The Neuropsychiatric Inventory (NPI) was used to assess the presence of delusions. Sixty-three additional matched healthy controls (HC) were selected. Repeated-measures ANCOVA models were used to investigate group-by-time effects on the volume of selected GM regions of interest and on cognitive performance. No neurocognitive differences were observed between patient groups prior to symptom onset. Greater episodic memory decline and GM loss in bilateral caudate nuclei, medio-temporal and midline cingulo-parietal regions were found in the PT-D compared with the PT-ND group. A pattern of faster GM loss in brain areas typically affected by AD and in cortical and subcortical targets of dopaminergic pathways, paralleled by worsening of episodic memory and behavioural symptoms, may explain the emergence of delusions in patients with AD.
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2
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Pezzoli S, Manca R, Cagnin A, Venneri A. A Multimodal Neuroimaging and Neuropsychological Study of Visual Hallucinations in Alzheimer’s Disease. J Alzheimers Dis 2022; 89:133-149. [DOI: 10.3233/jad-215107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Hallucinations in Alzheimer’s disease (AD) have been linked to more severe cognitive and functional decline. However, research on visual hallucinations (VH), the most common type of hallucinations in AD, is limited. Objective: To investigate the cognitive and cerebral macrostructural and metabolic features associated with VH in AD. Methods: Twenty-four AD patients with VH, 24 with no VH (NVH), and 24 cognitively normal (CN) matched controls were selected from the Alzheimer’s Disease Neuroimaging Initiative (ADNI) database. Differences in regional gray matter (GM) volumes and cognitive performance were investigated with whole brain voxel-based morphometry analyses of MRI structural brain scans, and analyses of neuropsychological tests. Glucose metabolic changes were explored in a subsample of patients who had FDG-PET scans available. Results: More severe visuoconstructive and attentional deficits were found in AD VH compared with NVH. GM atrophy and hypometabolism were detected in occipital and temporal areas in VH patients in comparison with CN. On the other hand, NVH patients had atrophy and hypometabolism mainly in temporal areas. No differences in GM volume and glucose metabolism were found in the direct comparison between AD VH and NVH. Conclusion: In addition to the pattern of brain abnormalities typical of AD, occipital alterations were observed in patients with VH compared with CN. More severe visuoconstructive and attentional deficits were found in AD VH when directly compared with NVH, and might contribute to the emergence of VH in AD.
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Affiliation(s)
- Stefania Pezzoli
- Helen Wills Neuroscience Institute, University of California Berkeley, Berkeley, CA, USA
- Molecular Biophysics and Integrated Bioimaging, Lawrence Berkeley National Laboratory, Berkeley, CA, USA
| | - Riccardo Manca
- Department of Life Sciences, Brunel University London, London, UK
| | - Annachiara Cagnin
- Department of Neurosciences, University of Padua, Padua, Italy
- Padua Neuroscience Center (PNC), University of Padua, Padua, Italy
| | - Annalena Venneri
- Department of Life Sciences, Brunel University London, London, UK
- Department of Medicine and Surgery, University of Parma, Parma, Italy
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3
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Benmelouka AY, Ouerdane Y, Outani O, Alnasser YT, Alghamdi BS, Perveen A, Ashraf GM, Ebada MA. Alzheimer's Disease-Related Psychosis: An Overview of Clinical Manifestations, Pathogenesis, and Current Treatment. Curr Alzheimer Res 2022; 19:285-301. [PMID: 35440308 DOI: 10.2174/1567205019666220418151914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/25/2022] [Accepted: 03/06/2022] [Indexed: 11/22/2022]
Abstract
Behavioral and psychotic manifestations, including aggression, delusions, and hallucinations, are frequent comorbidities in patients with debilitating nervous illnesses such as Alzheimer's disease (AD), Amyotrophic Lateral Sclerosis, Multiple Sclerosis, and Parkinson's disease. AD-related psychosis may be linked to a poor disease prognosis, highlighting that early detection and management are mandatory. The manifestations are variable and may be very heterogeneous, imposing a real diagnostic issue. Some assessment tools such as BEHAVE-AD, CERAD-BRSD, and the Psycho-Sensory Hallucinations Scale have been designed to facilitate the diagnosis. The mechanisms behind neurodegeneration-related psychosis are complex and are not fully understood, imposing a burden on researchers to find appropriate management modalities. Familial history and some genetic disturbances may have a determinant role in these delusions and hallucinations in cases with AD. The loss of neuronal cells, atrophy in some regions of the central nervous, and synaptic dysfunction may also contribute to these comorbidities. Furthermore, inflammatory disturbances triggered by pro-inflammatory agents such as interleukins and tumor necrosis factors are stratified among the potential risk factors of the onset of numerous psychotic symptoms in Alzheimer's patients. Little is known about the possible management tools; therefore, it is urgent to conduct well-designed trials to investigate pharmacological and non-pharmacological interventions that can improve the care process of these patients. This review summarizes the current findings regarding the AD-related psychosis symptoms, pathological features, assessment, and management.
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Affiliation(s)
| | | | - Oumaima Outani
- Faculty of Medicine and Pharmacy of Rabat, Mohammed 5 University
| | | | - Badrah S Alghamdi
- Neuroscience Unit, Faculty of Medicine, King Abdulaziz University, Jeddah.,Pre-Clinical Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah
| | - Asma Perveen
- Glocal University, Mirzapur Pole, Saharanpur, Uttar Pradesh
| | - Ghulam Md Ashraf
- Pre-Clinical Research Unit, King Fahd Medical Research Center, King Abdulaziz University, Jeddah.,Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah
| | - Mahmoud Ahmed Ebada
- Faculty of Medicine, Zagazig University, Zagazig, Al-Sharkia.,Internal Medicine Resident, Ministry of Health and Population of Egypt, Cairo
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4
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Gomar JJ, Tan G, Halpern J, Gordon ML, Greenwald B, Koppel J. Increased retention of tau PET ligand [ 18F]-AV1451 in Alzheimer's Disease Psychosis. Transl Psychiatry 2022; 12:82. [PMID: 35217635 PMCID: PMC8881582 DOI: 10.1038/s41398-022-01850-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 02/04/2022] [Accepted: 02/09/2022] [Indexed: 11/09/2022] Open
Abstract
Psychosis in Alzheimer's disease (AD) represents a distinct disease subtype with a more rapid progression of illness evidenced by an increased velocity of cognitive decline and a hastened mortality. Previous biomarker and post-mortem studies have implicated tau neuropathology as a possible mediator of the accelerated decline in AD psychosis. Tau positron emission tomography (PET) neuroimaging provides the opportunity to evaluate tau pathology in-vivo, so that clinical symptomatology can be correlated with disease pathology. [18F]-AV1451 (Flortaucipir) is a PET ligand with high affinity for insoluble paired-helical filaments (PHFs) of hyperphosphorylated tau. In order to determine whether the development of psychosis and worsened prognosis in AD is associated with an increased burden of tau pathology that can be identified with tau imaging, we identified subjects within the Alzheimer's disease neuroimaging initiative (ADNI) who had [18F]-AV1451 imaging at baseline and became psychotic over the course of the study (N = 17) and matched them 1:3 for gender, age, and education to subjects who had [18F]-AV1451 imaging at baseline and did not become psychotic (N = 50). We compared baseline [18F]-AV1451 retention, in addition to cognitive and functional baseline and longitudinal change, in those who became psychotic over the course of participation in ADNI with those who did not. Results suggest that increases in tau pathology in frontal, medial temporal, and occipital cortices, visualized with [18F]-AV1451 binding, are associated with psychosis and a more rapid cognitive and functional decline.
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Affiliation(s)
- J. J. Gomar
- grid.250903.d0000 0000 9566 0634Feinstein Institutes for Medical Research, Manhassett, NY USA
| | - G. Tan
- grid.250903.d0000 0000 9566 0634Feinstein Institutes for Medical Research, Manhassett, NY USA
| | - J. Halpern
- grid.250903.d0000 0000 9566 0634Feinstein Institutes for Medical Research, Manhassett, NY USA
| | - M. L. Gordon
- grid.250903.d0000 0000 9566 0634Feinstein Institutes for Medical Research, Manhassett, NY USA ,grid.416477.70000 0001 2168 3646Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY USA
| | - B. Greenwald
- grid.416477.70000 0001 2168 3646Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY USA
| | - J. Koppel
- grid.250903.d0000 0000 9566 0634Feinstein Institutes for Medical Research, Manhassett, NY USA ,grid.416477.70000 0001 2168 3646Department of Psychiatry, Zucker Hillside Hospital, Northwell Health, Glen Oaks, NY USA
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5
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The Role of Decreased Cortical Thickness and Volume of Medial Temporal Lobe Structures in Predicting Incident Psychosis in Patients With Alzheimer's Disease: A Prospective Longitudinal MRI Study. Am J Geriatr Psychiatry 2022; 30:46-53. [PMID: 34074610 DOI: 10.1016/j.jagp.2021.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/12/2021] [Accepted: 04/21/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To investigate the effect of decreased cortical thickness or volume of medial temporal lobe structures on the risk of incident psychosis in patients with AD. DESIGN, SETTING, AND PARTICIPANTS This hospital-based prospective longitudinal study enrolled 109 patients with AD. All patients with AD were evaluated at 3-month intervals to investigate the effect of decreased cortical thickness or volume of medial temporal lobe structures on the risk of incident psychosis in patients with AD. OUTCOME MEASURE The main outcome measure was time-to-progression from AD to incident psychosis. The thickness or volume of medial temporal lobe structures (i.e., the hippocampus, entorhinal cortex, and parahippocampus) were measured using magnetic resonance imaging and the Freesurfer automated segmentation pipeline at baseline. RESULTS Multivariate Cox proportional hazards regression analysis revealed that a decreased cortical thickness or volume of medial temporal region was associated with a higher risk of incident psychosis in patients with AD. The hazard ratios for decreased cortical thickness of the left entorhinal cortex and decreased cortical volume of the right hippocampus were 4.291 (95% confidence interval [CI], 1.196-15.384) and 2.680 [(CI, 1.003-1.196]), respectively. CONCLUSION Our study revealed that decreased cortical thickness or volume of medial temporal sub-regions is a risk factor for incident psychosis in patients with AD. A careful assessment of the thickness or volume of the medial temporal lobe structures in AD may improve early detection and intervention of psychosis in AD.
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Jeong HJ, Lee YM, Park JM, Lee BD, Moon E, Suh H, Kim HJ, Pak K, Choi KU, Chung YI. Reduced Thickness of the Anterior Cingulate Cortex as a Predictor of Amnestic-Mild Cognitive Impairment Conversion to Alzheimer's Disease with Psychosis. J Alzheimers Dis 2021; 84:1709-1717. [PMID: 34719496 DOI: 10.3233/jad-215005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND A long-term follow-up study in patients with amnestic mild cognitive impairment (aMCI) is needed to elucidate the association between regional brain volume and psychopathological mechanisms of Alzheimer's disease with psychosis (AD + P). OBJECTIVE The purpose of this study was to investigate the effect of the thickness of the angular cingulate cortex (ACC) on the risk of AD + P conversion in patients with aMCI. METHODS This was a hospital-based prospective longitudinal study including 174 patients with aMCI. The main outcome measure was time-to-progression from aMCI to AD + P. Subregions of the ACC (rostral ACC, rACC; caudal ACC, cACC) and hippocampus (HC) were measured as regions of interest with magnetic resonance imaging and the Freesurfer analysis at baseline. Survival analysis with time to incident AD + P as an event variable was calculated with Cox proportional hazards models using the subregions of the ACC and HC as a continuous variable. RESULTS Cox proportional hazard analyses showed that the risk of AD + P was associated with sub-regional ACC thickness but not HC volume: reduced cortical thickness of the left cACC (HR [95%CI], 0.224 [0.087-0.575], p = 0.002), right cACC (HR [95%CI], 0.318 [0.132-0.768], p = 0.011). This association of the cACC with the risk of AD also remained significant when adjusted for HC volume. CONCLUSION We found that reduced cortical thickness of the cACC is a predictor of aMCI conversion to AD + P, independent of HC, suggesting that the ACC plays a vital role in the underlying pathogenesis of AD + P.
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Affiliation(s)
- Hee-Jeong Jeong
- Department of Psychiatry, Pusan National University School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Young-Min Lee
- Department of Psychiatry, Pusan National University School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Je-Min Park
- Department of Psychiatry, Pusan National University School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Byung-Dae Lee
- Department of Psychiatry, Pusan National University School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Eunsoo Moon
- Department of Psychiatry, Pusan National University School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Hwagyu Suh
- Department of Psychiatry, Pusan National University School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Hak-Jin Kim
- Department of Radiology, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Kyoungjune Pak
- Department of Nuclear Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Kyung-Un Choi
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea.,Department of Pathology, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Young-In Chung
- Department of Psychiatry, Pusan National University School of Medicine, Yangsan, Republic of Korea
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7
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Cappelletto P, Polito C, Berti V, Lombardi G, Lucidi G, Bessi V, Sorbi S, Ferrari C. Behavioural disorders in Alzheimer's disease: the descriptive and predictive role of brain 18 F-fluorodesoxyglucose-positron emission tomography. Psychogeriatrics 2021; 21:514-520. [PMID: 33881215 DOI: 10.1111/psyg.12699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 03/30/2021] [Accepted: 04/05/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Alzheimer's disease (AD) has a high incidence in the elderly. Besides cognitive disorders, patients may also develop behavioural and psychological symptoms of dementia (BPSD), which can be particularly disabling for patients and families. BPSD encompass a wide range of symptoms, among which psychotic symptoms and disruptive behaviours often prompt the first related hospitalization and request for family support. The aetiological mechanism of BPSD has not yet been clarified, and no predictive or risk factors have been identified. The main objectives of our study are to describe the frequency of aggression/agitation and psychotic symptoms, defined 'positive BPSD', in a cohort of 60 AD patients, identify areas of the brain involved in behavioural symptomatology through brain 18 F-fluorodesoxyglucose-positron emission tomography (FDG-PET), and investigate a potential predictive role of brain FDG-PET in BPSD development. METHODS A cohort of 60 AD patients was retrospectively enrolled and regularly followed for at least 3 years. Each subject underwent brain FDG-PET at the time of diagnosis. Patients were divided into three groups based on the presence of behavioural disturbances: present, absent, and developed later. RESULTS Of the 60 AD patients in the cohort, 52% had positive BPSD: 17 at baseline and 14 during the 3-year follow-up. FDG-PET identified an association between hypometabolism in the bilateral temporal lobes and the presence of BPSD, and showed initial hypometabolism in the postero-temporal lobes 3 years before symptom onset. CONCLUSIONS Positive BPSD are frequently manifested in AD. Our study identified the temporal lobes as the neurobiological substrate of positive BPSD and FDG-PET as a potential instument to predict their developement. Temporal lobes are involved in processing facial expression and recognizing emotions; an impairment of these functions could cause delusions and agitated/aggressive behaviour. To confirm the potential predictive role of FDG-PET in the onset of BPSD in AD, further studies are needed.
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Affiliation(s)
- Pietro Cappelletto
- Department of Pediatric Neurology Unit and Laboratories, A. Meyer Children's Hospital, University of Florence, Florence, Italy
| | - Cristina Polito
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", Nuclear Medicine Unit, University of Florence, Florence, Italy
| | - Valentina Berti
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", Nuclear Medicine Unit, University of Florence, Florence, Italy
| | | | - Giulia Lucidi
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.,Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Valentina Bessi
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Sandro Sorbi
- IRCCS Fondazione Don Carlo Gnocchi, Florence, Italy.,Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Camilla Ferrari
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
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8
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Boublay N, Bouet R, Dorey JM, Padovan C, Makaroff Z, Fédérico D, Gallice I, Barrellon MO, Robert P, Moreaud O, Rouch I, Krolak-Salmon P. Brain Volume Predicts Behavioral and Psychological Symptoms in Alzheimer's Disease. J Alzheimers Dis 2021; 73:1343-1353. [PMID: 31903989 DOI: 10.3233/jad-190612] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Behavioral and psychological symptoms of dementia (BPSD) are frequent and troublesome for patients and caregivers. Considering possible preventive approaches, a better understanding of underlying neural correlates of BPSD is crucial. OBJECTIVE The aim is to assess whether brain regional volume predicts behavioral changes in mild AD. METHODS This work took part from the PACO study, a multicenter and prospective study that included 252 patients with mild AD from 2009 to 2014. Fifty-three patients were retained. Forty healthy matched control subjects from the ADNI cohort were included as controls. Voxel-based morphometry analysis was conducted to assess regional brain volume using baseline MRI scans as a predictor of future behavioral changes over a period of 18 months. Behavior was assessed at baseline and longitudinally at 6-month intervals using the shortened form of the Neuropsychiatric Inventory (NPI). RESULTS The volume of 23 brain structures in frontal, temporal, parietal, occipital, subcortical regions and cerebellum predicted the evolution of NPI scores. Frontal volume was the most powerful predictor with frontal gyri, anterior cingulate cortex, and orbital gyri being particularly involved. CONCLUSION To our knowledge, this is the first study assessing regional brain volumes as predictors of behavioral changes considered at earlier stages of AD. Up to 23 brain structures were associated with an increased risk of developing BPSD. Frontal lobe volume was the strongest predictor of future evolution of NPI. The involvement of multiple structures in the prediction of behavior suggests a role of the main large-scale networks involved in cognition.
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Affiliation(s)
- Nawele Boublay
- Clinical and Research Memory Center of Lyon, Hospital of Charpennes, Lyon Institute for Elderly, University Hospital of Lyon, Lyon, France.,INSERM, U1028; CNRS, UMR5292; Lyon Neuroscience Research Center, Brain Dynamics and Cognition Team, Lyon, France.,University Lyon, Lyon, France.,Hospices Civils de Lyon, Pôle Information Médicale Evaluation Recherche, Lyon, France
| | - Romain Bouet
- INSERM, U1028; CNRS, UMR5292; Lyon Neuroscience Research Center, Brain Dynamics and Cognition Team, Lyon, France
| | | | | | - Zaza Makaroff
- Clinical and Research Memory Center of Lyon, Hospital of Charpennes, Lyon Institute for Elderly, University Hospital of Lyon, Lyon, France
| | - Denis Fédérico
- Clinical and Research Memory Center of Lyon, Hospital of Charpennes, Lyon Institute for Elderly, University Hospital of Lyon, Lyon, France
| | - Isabelle Gallice
- Center Hospitalier Saint Jean de Dieu, Pôle de Gérontopsychiatrie, Lyon, France
| | | | - Philippe Robert
- CoBTeK lab Clinical and Research Memory Center and CHU of Nice, Université Côte d'Azur, Nice, France
| | - Olivier Moreaud
- Clinical and Research Memory Center and CHU of Grenoble Arc Alpin, Pôle de Psychiatrie et Neurologie, Laboratoire de Psychologie et Neurocognition, CNRS UMR 5105, Grenoble, France
| | - Isabelle Rouch
- Clinical and Research Memory Center of Lyon, Hospital of Charpennes, Lyon Institute for Elderly, University Hospital of Lyon, Lyon, France.,Center Mémoire de Ressources et de Recherche, Neurology unit, University Hospital of Saint-Etienne, Saint Etienne, France
| | - Pierre Krolak-Salmon
- Clinical and Research Memory Center of Lyon, Hospital of Charpennes, Lyon Institute for Elderly, University Hospital of Lyon, Lyon, France.,INSERM, U1028; CNRS, UMR5292; Lyon Neuroscience Research Center, Brain Dynamics and Cognition Team, Lyon, France.,University Lyon, Lyon, France.,Clinical Research Center CRC - VCF (Vieillissement - Cerveau - Fragilité), Hospital of Charpennes, University Hospital of Lyon, Lyon, France
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9
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Burstein ES. Relevance of 5-HT 2A Receptor Modulation of Pyramidal Cell Excitability for Dementia-Related Psychosis: Implications for Pharmacotherapy. CNS Drugs 2021; 35:727-741. [PMID: 34224112 PMCID: PMC8310514 DOI: 10.1007/s40263-021-00836-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 01/05/2023]
Abstract
Psychosis occurs across a wide variety of dementias with differing etiologies, including Alzheimer's dementia, Parkinson's dementia, Lewy body dementia, frontotemporal dementia, and vascular dementia. Pimavanserin, a selective serotonin 5-HT2A receptor (5-HT2AR) inverse agonist, has shown promising results in clinical trials by reducing the frequency and/or severity of hallucinations and delusions and the risk of relapse of these symptoms in patients with dementia-related psychosis. A literature review was conducted to identify mechanisms that explain the role of 5-HT2ARs in both the etiology and treatment of dementia-related psychosis. This review revealed that most pathological changes commonly associated with neurodegenerative diseases cause one or more of the following events to occur: reduced synaptic contact of gamma aminobutyric acid (GABA)-ergic interneurons with glutamatergic pyramidal cells, reduced cortical innervation from subcortical structures, and altered 5-HT2AR expression levels. Each of these events promotes increased pyramidal cell hyperexcitability and disruption of excitatory/inhibitory balance, facilitating emergence of psychotic behaviors. The brain regions affected by these pathological changes largely coincide with areas expressing high levels of 5-HT2ARs. At the cellular level, 5-HT2ARs are most highly expressed on cortical glutamatergic pyramidal cells, where they regulate pyramidal cell excitability. The common effects of different neurodegenerative diseases on pyramidal cell excitability together with the close anatomical and functional connection of 5-HT2ARs to pyramidal cell excitability may explain why suppressing 5-HT2AR activity could be an effective strategy to treat dementia-related psychosis.
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Affiliation(s)
- Ethan S. Burstein
- Acadia Pharmaceuticals Inc, 12830 El Camino Real, Suite 400, San Diego, CA 92130 USA
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10
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García-Alberca JM, Mendoza S, Gris E, Royo JL, Cruz-Gamero JM, García-Casares N. White matter lesions and temporal atrophy are associated with cognitive and neuropsychiatric symptoms in patients with hypertension and Alzheimer's disease. Int J Geriatr Psychiatry 2020; 35:1292-1300. [PMID: 32584440 DOI: 10.1002/gps.5366] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/20/2020] [Accepted: 06/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVES An increasing evidence suggests hypertension (HTN) could be linked to cognitive impairment and incident Alzheimer's disease (AD). The precise mechanisms linking HTN and AD are not well-known. The aim of this study was to assess the putative association between HTN and AD. METHODS We assessed in patients with AD associations between HTN and demographic and clinical data, vascular risk factors, treatments, APOE genotypes, brain white matter hyperintensities (WMH), and medial temporal atrophy (MTA) in multivariate analysis of covariance. RESULTS We studied 92 patients with AD (mean ± SD age: 72.12 ± 6.91; women: 66.30%). Patients with HTN had significantly worse cognitive and functional status and higher frequency and severity of neuropsychiatric symptoms (P = .010). Magnetic resonance imaging analyzes showed significant increases in WMH (P = .018) and in MTA (P = .012) in patients with AD with HTN compared with those without HTN. CONCLUSIONS Neuroimaging burden (MTA and higher degree of severity of WMH) among patients with AD and HTN are associated with the impaired cognitive function and neuropsychiatric symptoms.
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Affiliation(s)
| | - Silvia Mendoza
- Alzheimer Research Center and Memory Clinic, Andalusian Institute for Neuroscience, Málaga, Spain
| | - Esther Gris
- Alzheimer Research Center and Memory Clinic, Andalusian Institute for Neuroscience, Málaga, Spain
| | - José Luis Royo
- Department of Surgery, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain
| | - José Manuel Cruz-Gamero
- Department of Surgery, Biochemistry and Immunology, School of Medicine, University of Málaga, Málaga, Spain
| | - Natalia García-Casares
- Department of Medicine, School of Medicine, University of Málaga, Research Medical Center of Málaga University, Biomedical Research Institute of Málaga, Málaga, Spain
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11
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Gottesman RT, Stern Y. Behavioral and Psychiatric Symptoms of Dementia and Rate of Decline in Alzheimer's Disease. Front Pharmacol 2019; 10:1062. [PMID: 31616296 PMCID: PMC6768941 DOI: 10.3389/fphar.2019.01062] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/20/2019] [Indexed: 12/20/2022] Open
Abstract
Alzheimer’s disease causes both cognitive and non-cognitive symptoms. There is increasing evidence that the presentation and course of Alzheimer’s disease is highly heterogenous. This heterogeneity presents challenges to patients, their families, and clinicians due to the difficulty in prognosticating future symptoms and functional impairment. Behavioral and psychiatric symptoms are emerging as a significant contributor to this clinical heterogeneity. These symptoms have been linked to multiple areas of neurodegeneration, which may suggest that they are representative of network-wide dysfunction in the brain. However, current diagnostic criteria for Alzheimer’s disease focus exclusively on the cognitive aspects of disease. Behavioral and psychiatric symptoms have been found in multiple studies to be related to disease severity and to contribute to disease progression over time. A better understanding of how behavioral and psychiatric symptoms relate to cognitive aspects of Alzheimer’s disease would help to refine the models of disease and hopefully lead to improved ability to develop therapeutic options for this devastating disease.
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Affiliation(s)
- Reena T Gottesman
- Division of Aging and Dementia, Department of Neurology, Columbia University Medical Center, New York, NY, United States
| | - Yaakov Stern
- Division of Cognitive Neuroscience, Department of Neurology, Columbia University Medical Center, New York, NY, United States
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12
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Connors MH, Ames D, Woodward M, Brodaty H. Psychosis and Clinical Outcomes in Alzheimer Disease: A Longitudinal Study. Am J Geriatr Psychiatry 2018; 26:304-313. [PMID: 29174998 DOI: 10.1016/j.jagp.2017.10.011] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Psychotic symptoms are a common feature in Alzheimer disease (AD), occurring in approximately 40% of patients. These symptoms are associated with worse clinical outcomes. Comparatively little research, however, has distinguished delusions and hallucinations, which may have distinct clinical, neuropathological, and genetic correlates. To address this, the current study examined the clinical outcomes associated with delusions and hallucinations in AD. DESIGN Three-year observational study. SETTING Nine memory clinics in Australia. PARTICIPANTS A total of 445 patients with AD. MEASUREMENTS Measures of neuropsychiatric symptoms, dementia severity, cognition, function, caregiver burden, and medication use were completed annually for 3 years with additional assessments at 3 months and 6 months in the first year. Mortality data were obtained from state registries approximately 5 years after the study. RESULTS Of 445 patients, 102 (22.9%) developed only delusions, 39 (8.8%) developed only hallucinations, and 84 (18.9%) developed both symptoms. Delusions and hallucinations were both associated with greater dementia severity, poorer cognition and function, higher levels of other neuropsychiatric symptoms, and greater caregiver burden. The presence of both symptoms was associated with worse outcomes than only one of these symptoms. Delusions, both by themselves and in combination with hallucinations, predicted institutionalization. Antipsychotic medication use predicted mortality. CONCLUSIONS Delusions and hallucinations independently and in combination are associated with poor clinical outcomes. The findings highlight the challenges managing these patients, particularly given the high levels of caregiver burden associated with psychotic symptoms and the likely mortality arising from antipsychotic medication.
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Affiliation(s)
- Michael H Connors
- Dementia Centre for Research Collaboration, UNSW Sydney, Sydney, Australia; Centre for Healthy Brain Ageing, UNSW Sydney, Sydney, Australia
| | - David Ames
- National Ageing Research Institute, Melbourne, Australia; University of Melbourne Academic Unit for Psychiatry of Old Age, Melbourne, Australia
| | - Michael Woodward
- Aged Care, Austin Hospital, Heidelberg, Australia; Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Henry Brodaty
- Dementia Centre for Research Collaboration, UNSW Sydney, Sydney, Australia; Centre for Healthy Brain Ageing, UNSW Sydney, Sydney, Australia.
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Hypertension and Neuropsychiatric Symptoms in Patients with Drug-Naïve Alzheimer's Disease. Dement Neurocogn Disord 2017; 16:78-82. [PMID: 30906375 PMCID: PMC6427990 DOI: 10.12779/dnd.2017.16.3.78] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 09/10/2017] [Accepted: 09/10/2017] [Indexed: 11/30/2022] Open
Abstract
Background and Purpose Neuropsychiatric symptoms (NPS) such as anxiety, depression, and delusions affect up to 90% of all patients with Alzheimer's disease (AD). NPS is associated with significant caregiver burden and patient distress. Given the severe burden of NPS in AD, it is critical to know potential modifiable risk factors of NPS in AD. This study explores the association between hypertension and NPS in patients with drug-naïve AD. Methods We reviewed medical records of 149 patients with AD with (n=80) and without (n=69) hypertension. NPS were assessed using the Korean version of Neuropsychiatric Inventory (K-NPI). Affective, psychotic, and behavior symptom clusters were assessed separately. Results The total score of K-NPI was not significantly different between patients with AD with and without hypertension. Among K-NPI domains, scores of depression/dysphoria (p=0.045), anxiety (p=0.022), and apathy/indifference (p=0.037) were significantly higher in patients with AD with hypertension. Systolic blood pressure (BP) was associated with higher total K-NPI and affective symptom cluster scores. Diastolic BP was associated with affective symptom cluster scores. Conclusions Results suggest that hypertension increases risk of specific NPS in patients with AD. Among NPS, hypertension was associated with affective symptom cluster.
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Moonga I, Niccolini F, Wilson H, Pagano G, Politis M. Hypertension is associated with worse cognitive function and hippocampal hypometabolism in Alzheimer's disease. Eur J Neurol 2017; 24:1173-1182. [PMID: 28752644 DOI: 10.1111/ene.13374] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 06/12/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND AND PURPOSE A growing body of evidence suggests that cardiovascular disease risk factors including hypertension may be linked to sporadic Alzheimer's disease (AD). It is well known that hypertension is associated with cerebrovascular disease and vascular dementia on the basis of vascular remodeling. However, the mechanisms linking hypertension and AD remain unclear. METHODS We studied 197 patients with AD (86 male; mean age ± SD: 75.8 ± 7.4 years) from the Alzheimer's Disease Neuroimaging Initiative database with (n = 97) and without (n = 100) hypertension. We explored associations between hypertension and clinical, plasma, cerebrospinal fluid and imaging markers of AD pathology in order to elucidate the underlying mechanisms that may link AD and hypertension. RESULTS We found that patients with AD with hypertension had worse cognitive function (Alzheimer's disease Assessment Scale-cognitive subscale, P = 0.038) and higher neuropsychiatric symptom burden (Neuropsychiatric Inventory Questionnaire, P = 0.016) compared with those without hypertension. Patients with AD with hypertension showed reduced glucose hypometabolism in the right (P < 0.001) and left (P = 0.007) hippocampus. No differences were found in magnetic resonance imaging volumetric measurements, [18 F]florbetapir uptakes, plasma and cerebrospinal fluid between patients with AD with and without hypertension. CONCLUSIONS Although hypertension is associated with worse cognitive function, behavioural symptoms and hippocampal glucose hypometabolism, it is not associated with evidence of increased amyloid or tau pathology. Effective management of hypertension may potentially have a therapeutic role in the alleviation of symptoms in AD.
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Affiliation(s)
- I Moonga
- Neurodegeneration Imaging Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience (IOPPN), King's College London, London, UK
| | - F Niccolini
- Neurodegeneration Imaging Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience (IOPPN), King's College London, London, UK
| | - H Wilson
- Neurodegeneration Imaging Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience (IOPPN), King's College London, London, UK
| | - G Pagano
- Neurodegeneration Imaging Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience (IOPPN), King's College London, London, UK
| | - M Politis
- Neurodegeneration Imaging Group, Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience (IOPPN), King's College London, London, UK
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15
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Clinical and neurocognitive aspects of hallucinations in Alzheimer's disease. Neurosci Biobehav Rev 2017; 83:713-720. [PMID: 28235545 DOI: 10.1016/j.neubiorev.2017.02.021] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 02/17/2017] [Accepted: 02/20/2017] [Indexed: 01/14/2023]
Abstract
Due to their prevalence, hallucinations are considered as one of the most frequent psychotic symptoms in Alzheimer's disease (AD). These psychotic manifestations reduce patients' well-being, increase the burden of caregivers, contribute to early institutionalization, and are related with the course of cognitive decline in AD. Considering their consequences, we provide a comprehensive account of the current state of knowledge about the prevalence and characteristics of hallucinations in AD. We propose a comprehensive and testable theoretical model about hallucinations in AD: the ALZHA (ALZheimer and HAllucinations) model. In this model, neurological, genetic, cognitive, affective, and iatrogenic factors associated with hallucinations in AD are highlighted. According to the ALZHA model, hallucinations in AD first involve trait markers (i.e., cognitive deficits, neurological deficits, genetic predisposition and/or sensory deficits) to which state markers that may trigger these experiences are added (e.g., psychological distress and/or iatrogenic factors). Finally, we provide recommendations for assessment and management of these psychotic manifestations in AD, with the aim to benefit patients, caregivers, and health professionals.
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Abstract
Psychosis is relatively common in later life and can present in a wide variety of contexts, including early-onset and late-onset schizophrenia, delusional disorder, mood disorders, and various dementias. It can also occur as the result of numerous medical and neurological diseases and from the use of certain medications. Although identifying the cause of psychosis in older patients can be challenging, the unique clinical features associated with the different disorders can help in making the diagnosis. Accurate diagnosis of psychosis in older populations is essential, as its treatment varies depending on the context in which it appears. Despite the safety concerns regarding the use of antipsychotics in older patients, certain pharmacological treatments appear to be both efficacious and reasonably safe in treating psychosis in older populations. Additionally, although research is limited, numerous psychosocial therapies appear promising. This review summarizes the literature on the epidemiology, clinical characteristics, neuroimaging, and treatment of psychosis in later life, and serves as an update to past reviews on this topic.
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17
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Donovan NJ, Wadsworth LP, Lorius N, Locascio JJ, Rentz DM, Johnson KA, Sperling RA, Marshall GA. Regional cortical thinning predicts worsening apathy and hallucinations across the Alzheimer disease spectrum. Am J Geriatr Psychiatry 2014; 22:1168-79. [PMID: 23890751 PMCID: PMC3960369 DOI: 10.1016/j.jagp.2013.03.006] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 02/23/2013] [Accepted: 03/07/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To examine regions of cortical thinning and cerebrospinal fluid (CSF) Alzheimer disease (AD) biomarkers associated with apathy and hallucinations in a continuum of individuals including clinically normal elderly, mild cognitive impairment, and mild AD dementia. DESIGN Cross-sectional and longitudinal studies. SETTING Fifty-seven research sites across North America. PARTICIPANTS Eight-hundred twelve community-dwelling volunteers; 413 participants in the CSF sub-study. MEASUREMENTS Structural magnetic resonance imaging data and CSF concentrations of amyloid-β 1-42, total tau, and phosphorylated tau derived from the Alzheimer Disease Neuroimaging Initiative database were analyzed. Apathy and hallucinations were measured at baseline and over 3 years using the Neuropsychiatric Inventory-Questionnaire. General linear models and mixed effects models were used to evaluate the relationships among baseline cortical thickness in seven regions, and baseline CSF biomarkers, apathy, and hallucinations at baseline and longitudinally. Covariates included diagnosis, sex, age, apolipoprotein E genotype, premorbid intelligence, memory performance, processing speed, antidepressant use, and AD duration. RESULTS Reduced baseline inferior temporal cortical thickness was predictive of increasing apathy over time, and reduced supramarginal cortical thickness was predictive of increasing hallucinations over time. There was no association with cortical thickness at baseline. CSF biomarkers were not related to severity of apathy or hallucinations in cross-sectional or longitudinal analyses. CONCLUSIONS These results suggest that greater baseline temporal and parietal atrophy is associated with worsening apathy and hallucinations in a large AD spectrum cohort, while adjusting for multiple disease-related variables. Localized cortical neurodegeneration may contribute to the pathophysiology of apathy and hallucinations and their adverse consequences in AD.
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Affiliation(s)
- Nancy J. Donovan
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA,Correspondence and reprint requests to: Nancy J. Donovan, MD, Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, 221 Longwood Avenue, BL-104H, Boston, MA 02115, P: 617-732-8085, F: 617-264-6831, E:
| | - Lauren P. Wadsworth
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Natacha Lorius
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Joseph J. Locascio
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Dorene M. Rentz
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Psychiatry, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Keith A. Johnson
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Reisa A. Sperling
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Gad A. Marshall
- Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Koppel J, Jimenez H, Azose M, D'Abramo C, Acker C, Buthorn J, Greenwald BS, Lewis J, Lesser M, Liu Z, Davies P. Pathogenic tau species drive a psychosis-like phenotype in a mouse model of Alzheimer's disease. Behav Brain Res 2014; 275:27-33. [PMID: 25151619 DOI: 10.1016/j.bbr.2014.08.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/11/2014] [Accepted: 08/13/2014] [Indexed: 01/30/2023]
Abstract
Psychotic Alzheimer's disease (AD+P) is a rapidly progressive variant of AD associated with an increased burden of frontal tau pathology that affects up to 50% of those with AD, and is observed more commonly in females. To date, there are no safe and effective medication interventions with an indication for treatment in this condition, and there has been only very limited exploration of potential animal models for pre-clinical drug development. Pathogenic tau is over represented in the frontal cortex in AD+P, especially in females. In order to develop a candidate animal model of AD+P, we employed a tau mouse model with a heavy burden of frontal tau pathology, the rTg(tauP301L)4510 mouse, hereafter termed rTg4510. We explored deficits of prepulse inhibition of acoustic startle (PPI), a model of psychosis in rodents, and the correlation between pathogenic phospho-tau species associated with AD+P and PPI deficits in female mice. We found that female rTg4510 mice exhibit increasing PPI deficits relative to littermate controls from 4.5 to 5.5 months of age, and that these deficits are driven by insoluble fractions of the phospho-tau species pSer396/404, pSer202, and pThr231 found to be associated with human AD+P. This preliminary data suggests the utility of the rTg4510 mouse as a candidate disease model of human female AD+P. Further work expanded to include both genders and other behavioral outcome measures relevant to AD+P is necessary.
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Affiliation(s)
- J Koppel
- The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA.
| | - H Jimenez
- The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA
| | - M Azose
- Touro College, Brooklyn, NY, USA
| | - C D'Abramo
- The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA
| | - C Acker
- The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA
| | - J Buthorn
- The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA
| | - B S Greenwald
- The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA
| | - J Lewis
- Center for Translational Research in Neurodegenerative Disease, University of Florida College of Medicine, Gainesville, FL, USA
| | - M Lesser
- The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA
| | - Z Liu
- Hofstra University, Hempstead, LI, USA
| | - P Davies
- The Feinstein Institute for Medical Research, 350 Community Drive, Manhasset, NY 11030, USA
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Murray PS, Kumar S, Demichele-Sweet MAA, Sweet RA. Psychosis in Alzheimer's disease. Biol Psychiatry 2014; 75:542-52. [PMID: 24103379 PMCID: PMC4036443 DOI: 10.1016/j.biopsych.2013.08.020] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 07/22/2013] [Accepted: 08/19/2013] [Indexed: 12/13/2022]
Abstract
Psychotic symptoms, delusions and hallucinations, occur in approximately 50% of individuals with Alzheimer's disease (AD) (AD with psychosis [AD + P]). Pharmacotherapies for AD + P have limited efficacy and can increase short-term mortality. These observations have motivated efforts to identify the underlying biology of AD + P. Psychosis in AD indicates a more severe phenotype, with more rapid cognitive decline beginning even before psychosis onset. Neuroimaging studies suggest that AD + P subjects demonstrate greater cortical synaptic impairments than AD subjects without psychosis, reflected in reduced gray matter volume, reduced regional blood flow, and reduced regional glucose metabolism. Neuroimaging and available postmortem evidence further indicate that the impairments in AD + P, relative to AD subjects without psychosis, are localized to neocortex rather than medial temporal lobe. Neuropathologic studies provide consistent evidence of accelerated accumulation of hyperphosphorylated microtubule associated protein tau in AD + P. Finally, studies of familial aggregation of AD + P have established that the risk for psychosis in AD is, in part, genetically mediated. Although no genes are established as associated with AD + P, the first genome-wide association study of AD + P has generated some promising leads. The study of the neurobiology of AD + P is rapidly accelerating and may be poised for translational discovery. This process can be enhanced by identifying points of convergence and divergence with the neurobiology of AD proper and of schizophrenia, by innovative extension of current approaches, and by development of relevant animal models.
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Affiliation(s)
- Patrick S Murray
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania; Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, US Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Sanjeev Kumar
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Robert A Sweet
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania; Veterans Integrated Service Network 4 Mental Illness Research, Education and Clinical Center, US Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
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Banno K, Nakaaki S, Sato J, Torii K, Narumoto J, Miyata J, Hirono N, Furukawa TA, Mimura M, Akechi T. Neural basis of three dimensions of agitated behaviors in patients with Alzheimer disease. Neuropsychiatr Dis Treat 2014; 10:339-48. [PMID: 24600224 PMCID: PMC3933703 DOI: 10.2147/ndt.s57522] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Agitated behaviors are frequently observed in patients with Alzheimer disease (AD). The neural substrate underlying the agitated behaviors in dementia is unclear. We hypothesized that different dimensions of agitated behaviors are mediated by distinct neural systems. METHODS All the patients (n=32) underwent single photon emission computed tomography (SPECT). Using the Agitated Behavior in Dementia scale, we identified the relationships between regional cerebral blood flow (rCBF) patterns and the presence of each of three dimensions of agitated behavior (physically agitated behavior, verbally agitated behavior, and psychosis symptoms) in AD patients. Statistical parametric mapping (SPM) software was used to explore these neural correlations. RESULTS Physically agitated behavior was significantly correlated with lower rCBF values in the right superior temporal gyrus (Brodmann 22) and the right inferior frontal gyrus (Brodmann 47). Verbally agitated behavior was significantly associated with lower rCBF values in the left inferior frontal gyrus (Brodmann 46, 44) and the left insula (Brodmann 13). The psychosis symptoms were significantly correlated with lower rCBF values in the right angular gyrus (Brodmann 39) and the right occipital lobe (Brodmann 19). CONCLUSION Our results support the hypothesis that three different agitated behaviors may represent distinct neural networks in AD patients.
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Affiliation(s)
- Koichi Banno
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Shutaro Nakaaki
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Junko Sato
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Katsuyoshi Torii
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Jin Narumoto
- Department of Psychiatry, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Jun Miyata
- Department of Neuropsychiatry, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | | | - Toshi A Furukawa
- Departments of Health Promotion and Human Behavior and of Clinical Epidemiology, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuo Akechi
- Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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Koppel J, Greenwald BS. Optimal treatment of Alzheimer's disease psychosis: challenges and solutions. Neuropsychiatr Dis Treat 2014; 10:2253-62. [PMID: 25473289 PMCID: PMC4247130 DOI: 10.2147/ndt.s60837] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Psychotic symptoms emerging in the context of neurodegeneration as a consequence of Alzheimer's disease was recognized and documented by Alois Alzheimer himself in his description of the first reported case of the disease. Over a quarter of a century ago, in the context of attempting to develop prognostic markers of disease progression, psychosis was identified as an independent predictor of a more-rapid cognitive decline. This finding has been subsequently well replicated, rendering psychotic symptoms an important area of exploration in clinical history taking - above and beyond treatment necessity - as their presence has prognostic significance. Further, there is now a rapidly accreting body of research that suggests that psychosis in Alzheimer's disease (AD+P) is a heritable disease subtype that enjoys neuropathological specificity and localization. There is now hope that the elucidation of the neurobiology of the syndrome will pave the way to translational research eventuating in new treatments. To date, however, the primary treatments employed in alleviating the suffering caused by AD+P are the atypical antipsychotics. These agents are approved by the US Food and Drug Administration for the treatment of schizophrenia, but they have only marginal efficacy in treating AD+P and are associated with troubling levels of morbidity and mortality. For clinical approaches to AD+P to be optimized, this syndrome must be disentangled from other primary psychotic disorders, and recent scientific advances must be translated into disease-specific therapeutic interventions. Here we provide a review of atypical antipsychotic efficacy in AD+P, followed by an overview of critical neurobiological observations that point towards a frontal, tau-mediated model of disease, and we suggest a new preclinical animal model for future translational research.
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Affiliation(s)
- Jeremy Koppel
- The Feinstein Institute for Medical Research, North Shore-Long Island Jewish Health System, Manhasset, NY, USA ; Zucker Hillside Hospital, Hofstra North Shore-Long Island Jewish School of Medicine, Glen Oaks, NY, USA
| | - Blaine S Greenwald
- Zucker Hillside Hospital, Hofstra North Shore-Long Island Jewish School of Medicine, Glen Oaks, NY, USA
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Content of delusional thoughts in Alzheimer's disease and assessment of content-specific brain dysfunctions with BEHAVE-AD-FW and SPECT. Int Psychogeriatr 2013; 25:939-48. [PMID: 23433495 DOI: 10.1017/s1041610213000094] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND A consensus on the brain dysfunction(s) underlying the delusions of Alzheimer's Dementia (AD) remains to be achieved. The aim of the present study was to test the hypothesis that content-based categorization of delusional ideas manifests as dysfunction of category-specific brain regions. METHODS Fifty-nine consecutive first-visit AD outpatients underwent Single Photon Emission Computed Tomography (SPECT), Mini-Mental State Examination, and Behavioral Pathology in Alzheimer's Disease Frequency-Weighted Severity scale (BEHAVE-AD-FW) to assess cerebral blood flow (CBF), cognitive function, and delusion, respectively. SPECT images were analyzed by SPM5. RESULTS CBF decreased at the temporal poles and right inferior temporal gyrus in "delusion of theft," at the temporal poles in "suspiciousness/paranoia," at the right parahippocampal gyrus and insula in "abandonment," and at the right amygdala in "Residence is not home." CONCLUSIONS Our findings offer a perspective on the discrete categories of the pathological thoughts of AD patients that have previously been lumped together as "delusions." Dysfunction of the temporal poles may be associated with a socioemotional deterioration that may include pathological suspiciousness. Delusion of theft may be a manifestation of socioemotional deterioration and poor insight. Emotional factors may be essential for delusions of abandonment and "not home."
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Bettney L, Butt S, Morris J, Connolly A, McCollum C, Burns A, Purandare N. Investigating the stability of neuropsychiatric sub-syndromes with progression of dementia: a 2-year prospective study. Int J Geriatr Psychiatry 2012; 27:1118-23. [PMID: 22250004 DOI: 10.1002/gps.2829] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 10/26/2011] [Indexed: 11/08/2022]
Abstract
OBJECTIVES Previous studies have identified sub-syndromes of behavioral and psychological symptoms of dementia. But because of their cross-sectional design, the stability of these sub-syndromes over time remains unknown. METHOD Behavioral and psychological symptoms of dementia of 84 participants (out of an original sample of 144 patients) with Alzheimer's disease and vascular dementia were assessed by using the Neuropsychiatric Inventory every six months for two years. Principal component factor analysis with Varimax rotation was used to detect neuropsychiatric sub-syndromes at each time point. RESULTS The 12 symptoms were reduced to four factors at baseline, 12, 18, and 24 months and three factors at six months. None of the factor structures matched the four sub-syndromes previously identified by studies. The most stable group of symptoms were a combination of "psychosis" and "hyperactivity" symptoms (delusions, hallucinations, irritability, agitation), which became stable at 18 months. CONCLUSIONS The pattern of behavioral and psychological symptoms of dementia sub-syndromes over time has not been studied before, and this research suggests that some stability is evident particularly during the later stages of the disease process. These findings have implications for patients and their caregiver.
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Affiliation(s)
- Laura Bettney
- Manchester Mental Health and Social Care Trust, Park House, North Manchester General Hospital, Manchester, UK
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Wadsworth LP, Lorius N, Donovan NJ, Locascio JJ, Rentz DM, Johnson KA, Sperling RA, Marshall GA. Neuropsychiatric symptoms and global functional impairment along the Alzheimer's continuum. Dement Geriatr Cogn Disord 2012; 34:96-111. [PMID: 22922821 PMCID: PMC3549662 DOI: 10.1159/000342119] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Neuropsychiatric symptoms in Alzheimer's disease (AD) are highly prevalent. We sought to determine whether neuropsychiatric symptoms were related to global functional impairment at baseline and over a 3-year period in older normal control (NC), mild cognitive impairment (MCI) and mild AD dementia subjects. METHODS Eight hundred and twelve subjects (229 NC, 395 MCI, 188 AD) from the Alzheimer's Disease Neuroimaging Initiative study underwent cognitive and behavioral assessments over 3 years. RESULTS Greater hallucinations, anxiety and apathy were associated with greater global functional impairment at baseline, while the presence of hallucinations and apathy at baseline was associated with greater global functional impairment over time across all subjects. The following neuropsychiatric symptoms were not significantly associated with global functioning: delusions, agitation, depression, euphoria, disinhibition, irritability, aberrant motor behaviors, sleep and appetite. CONCLUSIONS These results suggest that increased baseline hallucinations, apathy and anxiety are associated with current and future disease progression in AD.
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Affiliation(s)
- Lauren P. Wadsworth
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Natacha Lorius
- Center for Alzheimer Research and Treatment, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Nancy J. Donovan
- Center for Alzheimer Research and Treatment, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA 02139, USA
| | - Joseph J. Locascio
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Dorene M. Rentz
- Center for Alzheimer Research and Treatment, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Keith A. Johnson
- Center for Alzheimer Research and Treatment, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Reisa A. Sperling
- Center for Alzheimer Research and Treatment, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Gad A. Marshall
- Center for Alzheimer Research and Treatment, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA,Correspondence to: Gad A. Marshall, MD, Center for Alzheimer Research and Treatment, Brigham and Women’s Hospital, 221 Longwood Avenue, BL-104H, Boston, MA 02115, P: 617-732-8085, F: 617-264-5212,
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Smith GS, Kramer E, Ma Y, Hermann CR, Dhawan V, Chaly T, Eidelberg D. Cholinergic modulation of the cerebral metabolic response to citalopram in Alzheimer's disease. Brain 2009; 132:392-401. [PMID: 19153152 PMCID: PMC2640217 DOI: 10.1093/brain/awn326] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 10/23/2008] [Accepted: 11/06/2008] [Indexed: 01/09/2023] Open
Abstract
Pre-clinical and human neuropharmacological evidence suggests a role of cholinergic modulation of monoamines as a pathophysiological and therapeutic mechanism in Alzheimer's disease. The present study measured the effects of treatment with the cholinesterase inhibitor and nicotinic receptor modulator, galantamine, on the cerebral metabolic response to the selective serotonin reuptake inhibitor, citalopram. Seven probable Alzheimer's disease patients and seven demographically comparable controls underwent two positron emission tomography (PET) glucose metabolism scans, after administration of a saline placebo infusion (Day 1) and after citalopram (40 mg, IV, Day 2). The scan protocol was repeated in the Alzheimer's disease patients 2 months after titration to a 24 mg galantamine dose. At baseline, cerebral glucose metabolism was reduced in Alzheimer's disease patients relative to controls in right middle temporal, left posterior cingulate and parietal cortices (precuneus and inferior parietal lobule), as expected. Both groups demonstrated acute decreases in cerebral glucose metabolism after citalopram to a greater extent in the Alzheimer's disease patients. In the patients, relative to the controls, citalopram decreased glucose metabolism to a greater extent in middle frontal gyrus (bilaterally), left middle temporal gyrus and right posterior cingulate prior to treatment. Galantamine treatment alone increased metabolism in the right precuneus, right inferior parietal lobule and right middle occipital gyrus. In contrast, during galantamine treatment, citalopram increased metabolism in the right middle frontal gyrus, right post-central gyrus, right superior and middle temporal gyrus and right cerebellum. The combined cerebral metabolic effects of galantamine and citalopram suggest, consistent with preclinical data, a synergistic interaction of cholinergic and serotonergic systems.
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Affiliation(s)
- Gwenn S Smith
- Department of Psychiatry Research, The Zucker Hillside Hospital, Glen Oaks, NY 11004, USA.
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26
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Liperoti R, Pedone C, Corsonello A. Antipsychotics for the treatment of behavioral and psychological symptoms of dementia (BPSD). Curr Neuropharmacol 2008; 6:117-24. [PMID: 19305792 PMCID: PMC2647149 DOI: 10.2174/157015908784533860] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Revised: 10/19/2007] [Accepted: 11/11/2007] [Indexed: 01/26/2023] Open
Abstract
Behavioral and psychological symptoms of dementia (BPSD), i.e. verbal and physical aggression, agitation, psychotic symptoms (hallucinations and delusions), sleep disturbances, oppositional behavior, and wandering, are a common and potentially severe problem complicating dementia. Their prevalence is very high and it is estimated that up to 90% of patients with Alzheimer's disease (AD) may present at least one BPSD. Beside the obvious impact on the quality of life of people with dementia, BPSD are responsible for increased risk of patient institutionalization and increased costs. Furthermore, they are associated with caregivers' stress and depression. Drugs used include antipsychotics, antidepressants, anticonvulsivants, anxiolytics, cholinesterase inhibitors and N-methyl-D-aspartate receptor modulators. Among these, the most commonly used are anti-psychotics. These drugs have been used for many decades, but in the last years new compounds have been marketed with the promise of comparable efficacy but less frequent adverse effects (especially extra-pyramidal side effects). Their safety, however, has been challenged by data showing a potential increase in adverse cerebrovascular side effects and mortality. This review will summarize the pathophysiology and neuropharmacology of BPSD, it will describe the characteristics of the anti-psychotics most commonly used focusing on their efficacy and safety in BPSD.
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Affiliation(s)
- Rosa Liperoti
- Centro di Medicina dell'Invecchiamento, Dipartimento di Scienze Gerontologiche, Geriatriche e Fisiatriche, Università Cattolica del Sacro Cuore, Largo A. Gemelli, I-00168 Rome, Italy
| | - Claudio Pedone
- Area di Geriatria, Università Campus BioMedico, Via dei Compositori, I-00100 Rome, Italy
| | - Andrea Corsonello
- Fondazione San Raffaele, Cittadella della Carità, I-74100 Taranto, Italy
- Istituto Nazionale di Ricovero e Cura per Anziani (INRCA), I-87100 Cosenza, Italy
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27
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Abstract
OBJECTIVE To examine, in an exploratory analysis, the association between vascular conditions and the occurrence of neuropsychiatric symptoms (NPS) in a population-based sample of incident Alzheimer's disease (AD). METHODS The sample consisted of 254 participants, identified through two waves of assessment. NPS were assessed using the Neuropsychiatric Inventory. Prior to the onset of AD, data regarding a history of stroke, hypertension, hyperlipidemia, heart attack or coronary artery bypass graft (CABG), and diabetes were recorded. Logistic regression procedures were used to examine the relationship of each vascular condition to individual neuropsychiatric symptoms. Covariates considered were age, gender, education, APOE genotype, dementia severity, and overall health status. RESULTS One or more NPS were observed in 51% of participants. Depression was most common (25.8%), followed by apathy (18.6%), and irritability (17.7%). Least common were elation (0.8%), hallucinations (5.6%), and disinhibition (6.0%). Stroke prior to the onset of AD was associated with increased risk of delusions (OR = 4.76, p = 0.02), depression (OR = 3.87, p = 0.03), and apathy (OR = 4.48, p = 0.02). Hypertension was associated with increased risk of delusions (OR = 2.34, p = 0.02), anxiety (OR = 4.10, p = 0.002), and agitation/aggression (OR = 2.82, p = 0.01). No associations were observed between NPS and diabetes, hyperlipidemia, heart attack or CABG, or overall health. CONCLUSIONS Results suggest that a history of stroke and hypertension increase the risk of specific NPS in patients with AD. These conditions may disrupt neural circuitry in brain areas involved in NPS. Findings may provide an avenue for reduction in occurrence of NPS through the treatment or prevention of vascular risk conditions.
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28
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Psychosis in Alzheimer's Disease: Prevalence, Clinical Characteristics, Symptom Co-Morbidity, and Aetiology. SOUTH AFRICAN JOURNAL OF PSYCHOLOGY 2008. [DOI: 10.1177/008124630803800106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Alzheimer's disease was identified almost a century ago. Cognitive morbidity (deterioration in memory, attention, language, and executive functioning) was regarded as a sufficient index for the description and diagnosis of Alzheimer's disease. Within the cognitive discourse, the importance of neuropsychiatric and neurobehavioural referents was often eschewed. Recent research studies attest to the profound impact of the non-cognitive symptoms on the quality of life of both patient and caregiver. The purpose of this article is to review studies on psychosis in Alzheimer's disease, examine its prevalence, and discuss its manifestation with reference to the association between neuropathology and psychotic disturbances. The importance of clarifying the validity of the construct ‘psychosis in Alzheimer's disease’, the specificity of symptoms, and the phenomenology of subtypes with their distinct clinical and biological associations is addressed.
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29
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Lee E, Meguro K, Hashimoto R, Meguro M, Ishii H, Yamaguchi S, Mori E. Confabulations in episodic memory are associated with delusions in Alzheimer's disease. J Geriatr Psychiatry Neurol 2007; 20:34-40. [PMID: 17341769 DOI: 10.1177/0891988706292760] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although confabulations and delusions are observed in Alzheimer's disease, the relationship between the 2 has not been fully investigated. This study involved 50 patients with Alzheimer's disease and 10 healthy participants. After the patients were divided into delusional and nondelusional groups, confabulations and cognitive function were assessed. No confabulations appeared in the healthy participants, and only patients with Alzheimer's disease showed confabulations. The delusional group produced more confabulations on episodic subjects than on semantic subjects. There was a correlation between cognitive impairment and confabulations in semantic memory. These findings suggest that different mechanisms are involved in confabulations between semantic and episodic memories.
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Affiliation(s)
- Eunjoo Lee
- Department of Behavioral Neurology and Cognitive Neuro-science, Tohoku University Graduate School of Medicine, Sendai, Japan
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30
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Abstract
PURPOSE OF REVIEW Neuropsychiatric disturbances in dementia are prevalent, and research is uncovering their neurobiological correlates. RECENT FINDINGS Late-onset depression appears to be associated with Alzheimer's disease pathology at autopsy, and lifetime depression episodes may worsen Alzheimer's disease pathology in the hippocampus. Vascular disease and elevated homocysteine increase risk for both late-onset depression and Alzheimer's disease and may partly mediate their relationship. Monoamine changes are robust finding in Alzheimer's disease and may account for many observed depression symptoms. Risk of psychosis of Alzheimer's disease appears to be increased by several genes also implicated in schizophrenia (e.g., catechol-O-methyltransferase, neuregulin-1). Psychosis in dementia with Lewy bodies appears to be related to cholinergic deficits. Alzheimer's disease is associated with changes in the circadian sleep-wake cycles, including decreased night-time melatonin. Sleep apnea may be related to apolipoprotein E genotype and impact cognition in Alzheimer's disease. Rapid eye movement sleep behavior disorder is intricately related to synucleinopathies, such as dementia with Lewy bodies, but synuclein changes may not totally explain this relationship. SUMMARY Neuropsychiatric disturbances are a core feature of dementia and worsen many clinical outcomes. Among the most validated syndromes are depression, psychosis, and sleep disturbance of Alzheimer's disease. Neuropathology, neuroimaging, and genetic studies increasingly provide insight into the origins of these psychiatric symptoms in dementia.
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Affiliation(s)
- Thomas W Meeks
- Division of Geriatric Psychiatry, Department of Psychiatry, University of California, San Diego, and Veterans Affairs San Diego Healthcare System, San Diego, California 92161, USA.
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31
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Abstract
Assessments and clinical understanding of late-onset delusions in the elderly are inconsistent and often incomplete. In this review, we consider the prevalence, neurobehavioral features, and neuroanatomic correlations of delusions in elderly persons - those with documented cognitive decline and those with no evidence of cognitive decline. Both groups exhibit a common phenotype: delusions are either of persecution or of misidentification. Late-onset delusions show a nearly complete absence of the grandiose, mystical, or erotomanic content typical of early onset psychoses. Absent also from both elderly populations are formal thought disorders, thought insertions, and delusions of external control. Neuroimaging and behavioral studies suggest a frontotemporal localization of delusions in the elderly, with right hemispheric lateralization in delusional misidentification and left lateralization in delusions of persecution. We propose that delusions in the elderly reflect a common neuroanatomic and functional phenotype, and we discuss applications of our proposal to diagnosis and treatment.
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Affiliation(s)
- Anna EM Holt
- Brain and Cognitive Sciences Department, Massachusetts Institute of Technology, Boston, MA, USA
| | - Martin L Albert
- Department of Neurology, Boston University School of Medicine, Harold Goodglass Aphasia Research Center, VA Boston Healthcare System, Boston, MA, USA
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32
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Abstract
Since the introduction of the third edition of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition in 1980, schizophrenia has been widely diagnosed with good to excellent levels of reliability. This is no small feat, as prior to the 1970s the reliability of this diagnosis over time and place was very poor. Although there have been some changes in the diagnostic algorithm for schizophrenia with subsequent revisions of the Diagnostic and Statistical Manual of Mental Disorders, there has been little change in the overall classification scheme. However, there has also been relatively little movement toward enhancing the validity of this diagnosis. Although there is broad consensus that what we now call schizophrenia is probably very heterogeneous with respect to underlying etiology and pathophysiology, attempts to identify more valid subtypes or dimensions have not progressed to the point that they are likely to be incorporated into diagnostic systems any time soon. The limited progress in defining more valid disease categories has increasingly important clinical implications as the field moves more and more to treatment by preset algorithms that are typically driven by diagnosis.
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Affiliation(s)
- Laurie M McCormick
- Iowa Consortium for Mental Health, Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
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Holthoff VA, Beuthien-Baumann B, Kalbe E, Lüdecke S, Lenz O, Zündorf G, Spirling S, Schierz K, Winiecki P, Sorbi S, Herholz K. Regional cerebral metabolism in early Alzheimer's disease with clinically significant apathy or depression. Biol Psychiatry 2005; 57:412-21. [PMID: 15705358 DOI: 10.1016/j.biopsych.2004.11.035] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2004] [Revised: 11/08/2004] [Accepted: 11/18/2004] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alzheimer's disease (AD) is clinically characterized by cognitive impairment and behavioral disturbances. The aim of the study was to identify regional alterations in brain function associated with neuropsychiatric symptoms in early AD. METHODS Patients underwent measures of cerebral glucose metabolism applying positron emission tomography (PET) and (18)F-fluorodeoxyglucose. Neuropsychiatric symptoms were assessed using the Neuropsychiatric Inventory (NPI). Positron emission tomography images of patients suffering a neuropsychiatric symptom of clinical significance (NPI subscore for a specific item >/=4 points) were compared with the images of patients without the specific symptom under study (NPI subscore for a specific item = 0 points). RESULTS A total of 53 patients with AD (Mini-Mental State Examination [MMSE] 22.5 +/- 2.94 points) entered the study. Of all symptoms, apathy and depression were most frequently encountered. The patient group with apathy (n = 17) revealed significant decreases in left orbitofrontal regions when compared with patients free of apathy. Depression of clinical significance (n = 10) was associated with hypometabolism in dorsolateral prefrontal regions. CONCLUSIONS These findings support the notion that different functional circuits underlie apathy and depression in early AD.
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Affiliation(s)
- Vjera A Holthoff
- Department of Psychiatry and Psychotherapy, Dresden University of Technology, Germany
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Abstract
The term mild cognitive impairment (MCI) is used to identify individuals with worse cognitive performance than those with normal aging, and who are at risk of dementia, especially Alzheimer's disease (AD). Although the MCI concept is based on the presence of specific cognitive deficits, several studies have shown that these subjects can develop depression, disruptive behaviors (e.g., agitation, aggression), and psychosis. In this study, we examined the baseline psychiatric characteristics of 228 MCI (Mean age: 71.2, Mini-mental State Examination [MMSE] score: 25.9) and 427 mildly demented Probable AD (Mean age: 73.2; Mean MMSE score: 23.5) subjects from a referral dementia clinic. The psychiatric assessment was conducted by geriatric psychiatrists using semi-structured interviews. The proportion of subjects with major depression (MCI: 7.5% vs. Probable AD: 8%) and aggression (MCI: 10% vs. Probable AD: 12.5%) was similar in the two groups. There were more Probable AD patients with psychomotor agitation (52% vs. 38%), delusions (29% vs. 14%), and hallucinations (9% vs. 4%) than MCI subjects. Within MCI groups, we did not observe any differences between MCI subjects with amnesic syndrome versus MCI subjects with a much broader cognitive deficit. These results showed that the MCI syndrome is not circumscribed to a neuropsychological definition, but occurs with a wide range of psychiatric syndromes. Furthermore, it is possible that the development of disruptive behaviors and psychosis, in MCI subjects with no previous history of psychiatric illness, constitutes a strong indication that there is an underlying neurodegenerative disorder.
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Affiliation(s)
- Oscar L Lopez
- Alzheimer's Disease Research Center, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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35
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Abstract
PURPOSE OF REVIEW Neuropsychiatric, or non-cognitive symptoms are increasingly recognized as manifestations of dementias. RECENT FINDINGS In Alzheimer's disease, recent advances have included the identification of behavioral profiles, differentiation of apathy and depression, characterization of risk factors for psychosis and its links to agitation and aggression, and an analysis of depressive symptoms in the absence of major depression. Functional neuroimaging data mainly supported the role of the anterior cingulate in apathy. The orbitofrontal and anterior cingulate tangle burden were associated with agitation, and increased orbitofrontal and mid-temporal muscarinic M2 receptors with psychosis and hallucinations. Selected genetic polymorphisms of dopamine and serotonin receptors or transporters were linked with aggression, hallucinations or psychosis. When compared with other dementias, individuals with frontotemporal dementia disclosed, as expected, different behaviors and particularly aberrant social behavior. The frequency of delusions and visual hallucinations was increased in Parkinson's disease, Parkinson's disease with dementia, and dementia with Lewy bodies, suggesting common mechanisms such as Lewy body pathology and cholinergic deficiency. The latter was supported by an improvement of these symptoms by cholinesterase inhibitors. SUMMARY Future research directions include both clinical and basic neuroscience investigations. The detection of early neuropsychiatric symptoms might be a marker for dementia, and the possible existence of a mild neuropsychiatric impairment syndrome should be explored. More longitudinal studies with pathological confirmation will facilitate correlations with neuropsychiatric symptoms. Functional neuroimaging and behavioral neurogenetics will permit in-vivo correlations and consequently help patient management and care.
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Affiliation(s)
- Frédéric Assal
- UCLA School of Medicine, Los Angeles, CA 90095-1769, USA
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36
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Sweet RA, Panchalingam K, Pettegrew JW, McClure RJ, Hamilton RL, Lopez OL, Kaufer DI, DeKosky ST, Klunk WE. Psychosis in Alzheimer disease: postmortem magnetic resonance spectroscopy evidence of excess neuronal and membrane phospholipid pathology. Neurobiol Aging 2002; 23:547-53. [PMID: 12009504 DOI: 10.1016/s0197-4580(02)00009-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The presence of psychotic symptoms in Alzheimer Disease subjects (AD+psychosis, AD+P) is a marker for a phenotype characterized by more severe cognitive impairment and a more rapidly deteriorating course. Although AD+P has been inconsistently associated with more severe neuropathology, no prior studies have examined measures of neuronal and synaptic integrity. OBJECTIVE To determine whether AD+P is associated with evidence of disrupted neuronal and synaptic integrity, as indicated by magnetic resonance spectroscopy (MRS) measurement of N-acetyl-L-aspartate and the membrane breakdown products, glycerophosphocholine and glycerophosphoethanolamine. METHODS 31P and 1H MRS studies of perchloric acid extract from postmortem brain of AD subjects with and without a history of psychotic symptoms. All subjects were characterized for the presence of comorbid cortical Lewy body pathology and for history of neuroleptic use. Brain tissue from dorsolateral prefrontal, superior temporal, inferior parietal, and occipital cortex, amygdala, and cerebellum were examined in all subjects. Statistical analysis accounted for correlated observations across brain regions within-subjects. RESULTS AD+P subjects demonstrated significant elevations of glycerophosphoethanolamine and significant reductions of N-acetyl-L-aspartate. Between group differences were greatest in neocortical brain regions. CONCLUSION Excess impairment of neocortical neuronal and synaptic integrity may provide the structural substrate underlying AD+P. Confirmation of these findings using in vivo MRS measures is indicated.
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Affiliation(s)
- Robert A Sweet
- Department of Psychiatry, Division of Geriatrics, Neuropsychiatry, University of Pittsburgh School of Medicine, PA, USA.
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