Association of Dementia-Related Psychosis With Long-term Care Use and Death

Palliative Care for People With Very Severe to Extreme Behavioural and Psychological Symptoms of Dementia (BPSD): A Scoping Review

AIM

To explore current evidence regarding the provision of palliative care for individuals with very severe to extreme behavioural and psychological symptoms of dementia (BPSD) in a hospital setting.

DESIGN

Scoping review.

REPORTING METHOD

The PRISMA-ScR reporting guideline.

METHODS

The JBI guidelines for scoping reviews were followed. A data extraction form assisted in the identification of key findings via a process of content analysis.

DATA SOURCES

Studies were obtained from bibliographic databases of PubMed, CINAHL, and PsycINFO.

RESULTS

This review included six articles, and nine categories emerged from the findings. Symptom assessment and management, pain assessment challenges, atypical presentation of end-stage dementia, complex prescribing and treatment practices, principles of person-centred care, collaboration; training for health care professionals; emotional impact on staff; and family and caregivers.

CONCLUSIONS

This scoping review highlighted a significant gap in the literature regarding palliative care for people living with very severe to extreme BPSD in hospital settings. This review highlighted key differences in the presentation of people with BPSD needing palliative care. There is a need for tailored models of care, specialised training and education for health professionals, families, and carers, and recognition of dementia as a terminal illness.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The results of this review provide valuable insights into the level of understanding about the unique palliative care needs for people experiencing very severe to extreme BPSD, making an important contribution to the planning and development of future models of care.

IMPACT

Mapping the available literature highlights a paucity of research in palliative care for people with very severe to extreme BPSD in hospital settings. There is a need for rigorous research studies and models of care developed and informed by the evidence for this small population necessitating unique care needs.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Brexpiprazole for the Treatment of Agitation in Alzheimer's Disease Dementia: Clinical Uncertainties and the Path Forward

Brexpirazole was approved for the treatment of nonpsychotic agitation in Alzheimer's disease (AD) dementia by the United States Food and Drug Administration (FDA) in May 2023 after three phase 3 clinical trials found brexpiprazole 2 to 3 mg/day to be an effective and well-tolerated treatment for agitation in AD dementia, albeit with small effect sizes. It appeared to especially benefit dementia patients with severe agitation/aggression, but it took between 6 and 12 weeks across the three studies for the medication to separate from placebo. However, much remains unknown about its place in the psychopharmacological armamentarium for the treatment of AD dementia-related agitation, including the optimal duration of a brexpiprazole trial, bridging options during the time it takes for brexpiprazole to become effective, and whether it should be continued in the presence of or upon emergence of psychosis during treatment. This Research in Action article uses a case vignette to synthesize the findings of the brexpiprazole trials and apply them to clinical practice, highlight the current uncertainties associated with its use, and compare it with other psychopharmacological options for the treatment of agitation in AD dementia.

Refractory Psychosis as a Red Flag for End of Life in Individuals With Dementia With Lewy Bodies: A Case Series and Re-analysis of Prior Qualitative Data

OBJECTIVES

Many individuals with dementia with Lewy bodies (DLB) die of disease-related complications, but predicting the end of life can be challenging. We identified a phenotype associated with approaching end of life.

METHODS

We present 4 exemplar cases where individuals with DLB experienced refractory psychosis before death. We reviewed codebooks and quotes from 3 studies regarding end-of-life experiences in DLB to identify experiences that aligned with this phenotype.

RESULTS

In addition to the 4 cases, family caregivers in prior studies described prominent worsening of psychosis before death in some individuals with DLB. The worsening often occurred several months before death and was sometimes associated with rapid deterioration. Worsening psychosis was the prominent symptom and was not initially accompanied by cognitive or physical decline. In many cases, the refractory psychosis resulted in inpatient psychiatric hospitalization or residential care, but these scenarios were challenging because of the individual's behavior.

CONCLUSION

Refractory psychosis in DLB, particularly out of proportion to other symptoms, may be a signal of approaching the end of life. More research is needed to understand this phenomenon and to develop effective and safe treatments for psychosis in DLB.

Natural history and clinical outcomes in patients with Alzheimer's disease-related psychosis by antipsychotic treatment status in the United States

BACKGROUND

While some literature on clinical outcomes in persons with dementia-related psychosis exists, little is known regarding Alzheimer's disease-related psychosis (ADP).

OBJECTIVE

Describe demographic/clinical characteristics of adults with ADP and estimate incidence of clinical events by antipsychotic treatment status.

METHODS

This cohort study identified adults ≥65 years with Alzheimer's disease and incident psychosis (US Medicare database [2013-2018]) and no prior exposure to antipsychotics. Two nonmutually exclusive ADP subcohorts included: patients who initiated treatment with antipsychotic medications (antipsychotic users) and those who remained untreated (antipsychotic nonusers). Baseline characteristics were evaluated before psychosis diagnosis in untreated patients and before antipsychotic initiation in treated patients. Incidence rates were estimated for falls and fractures (composite and separately), seizure/epilepsy (new onset and any), and mortality.

RESULTS

145,333 ADP antipsychotic nonusers and 49,452 antipsychotic users were identified. Both cohorts had similar baseline demographics; however, antipsychotic users versus nonusers had higher baseline skilled nursing facility use (40.3% and 27.8%), mood (72.7% and 62.1%) and anxiety (70.9% and 57.3%) disorders, falls/fractures (39.5% and 33.8%), urinary tract infections (55.1% and 47.0%), and frailty index scores (76.0% and 69.7%). Crude incidence rates (95% confidence interval)/100 person-years in antipsychotic users and nonusers were 70.0 (68.9-71.2) and 55.8 (55.4-56.1) (falls/fractures composite), 69.0 (67.9-70.1) and 54.9 (54.5-55.2) (falls), 38.6 (38.1-39.0) and 33.0 (32.7-33.2) (mortality), and 45.8 (44.9-46.7) and 54.2 (53.9-54.6) (any seizure/epilepsy).

CONCLUSIONS

Antipsychotic initiators with ADP had a higher burden of some baseline comorbidities; experienced higher incidence of falls, fractures, and mortality; and had lower incidence of seizure/epilepsy than antipsychotic nonusers.

Early-onset Alzheimer dementia superimposed on schizophrenia: a rare case report

Disorganized behavior is a primary sign of schizophrenia. Yet it is not unique to schizophrenia. Recently, there has been a growing understanding that endogenous mental disorders could be a prodromal stage of neurodegenerative dementia. As a result, the connection between endogenous mental disorders and dementia has become a subject of significant interest. In the present study, a 49-year-old female with schizophrenia since the age of 17 was diagnosed with early-onset Alzheimer's disease after a detailed examination with PET and cerebrospinal fluid, despite suspicion of organic disease due to progressive forgetfulness, abnormal behavior and delusions. Schizophrenia is not the only disorder in which disorganized behavior is seen. When such a clinical phenomenon develops, other possible causes should be considered. Dementia is one of the most important of these causes. In a psychiatric disorder with disorganized behavior, other possible causes, especially dementia, should be considered.

Retrospective analyses evaluating the mortality risk associated with pimavanserin or other atypical antipsychotics in patients with Parkinson disease psychosis

Introduction

Parkinson's disease (PD) is associated with increased mortality risk (MR), reflecting progression of motor and nonmotor symptoms. PD psychosis (PDP), a common nonmotor symptom, increases with prolonged disease and elevates the MR of PD even further. Pimavanserin is the only FDA-approved treatment for PDP. This review summarizes real-world evidence around the MR of patients with PDP treated with pimavanserin versus off-label atypical antipsychotics.

Methods

A PubMed search was conducted using the following search terms: pimavanserin AND antipsychotic AND mortality AND Parkinson's disease AND psychosis. Inclusion criteria specified the entry of retrospective, observational, and open-label studies comparing pimavanserin to atypical antipsychotics or untreated controls.

Results

A total of 10 of the 32 articles met inclusion criteria. Among five comparisons of pimavanserin with atypical antipsychotics, two were large (n = 21,719; n = 21,975), representative, Medicare-database studies, which demonstrated comparable or lower all-cause pimavanserin MR. Among three pimavanserin versus control studies, two reported lower or comparable pimavanserin MR and one, long-term care study reported higher MR for pimavanserin versus non-pimavanserin treated patients with unknown PDP status. Two open-label extensions reported pimavanserin mortality rates of 6.45 and 18.8 deaths per 100 patient-years, which are comparable to, or lower than, mortality rates for PD, PDP, and other atypical antipsychotics. Most studies (70 %; 7 of 10) demonstrated pimavanserin's MR was lower than or similar to other atypical antipsychotics or untreated controls.

Conclusions

Pimavanserin did not increase the MR in PDP. Pimavanserin's MR appears to be comparable to or lower than other atypical antipsychotics prescribed for PDP, including quetiapine.

Clinical outcomes and treatment patterns of older adults with dementia-related psychosis by dementia type in the United States

Background

Little is known about the incidence of clinical events and treatment patterns among older adults with dementia-related psychosis. Given that dementia-related psychosis comprises various dementia types, this study describes the incidence of clinical events and treatment patterns by dementia type after patients with dementia are diagnosed with psychosis.

Methods

Adults aged ≥ 65 years with dementia and newly diagnosed with psychosis were identified in US Medicare claims during 2013–2018. Baseline characteristics were evaluated at the time of the psychosis diagnosis. After the initial psychosis diagnosis, incidence rates (IRs) of clinical events (e.g., falls/fractures, infections, healthcare utilization), mortality, and patterns of antipsychotic treatment were described for each dementia type (Alzheimer’s disease [AD], Parkinson’s disease dementia [PDD], dementia with Lewy bodies [DLB], frontotemporal dementia [FTD], vascular dementia [VD], and unspecified dementia). Daily mean cumulative counts were estimated to describe the incidence of recurrent events over time. Mortality was described using Kaplan–Meier survival curves.

Results

We identified 484,520 patients with dementia-related psychosis: mean age, 84 years (standard deviation, 7.8); female, 66%. At the time of psychosis diagnosis, the most prevalent type of dementia was unspecified dementia (56%), followed by AD (31%), VD (12%), PDD (10%), DLB (3%), and FTD (< 1%), and most patients had scores indicating severe illness on the Charlson Comorbidity Index (71%) and frailty index (62%). Across all dementia types, IRs (per 100 person-years) were high for emergency department visits, oral anti-infective use, and urinary tract infections after the initial psychosis diagnosis. Patients with DLB had the highest incidence of most clinical outcomes. After 1 year of follow-up, the cumulative probability of death was about 30% for all dementia types, and after 5 years, was about 80% among patients with DLB, VD, AD, or PDD and about 60%-65% among patients with FTD or unspecified dementia.

Conclusions

Patients with dementia-related psychosis had a high burden of comorbidities, frailty, emergency department visits, infections, and death. Specifically, after DRP diagnosis, patients with DLB and VD had the highest burden of clinical events of interest.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03489-3.

Medicare claims analysis of agents used to manage dementia-related psychosis: a treatment pattern study

Currently, no agents are approved in the USA to treat dementia-related psychosis. After failure of a nonpharmacologic approach to treatment, antipsychotics or divalproex is often prescribed. We characterized existing treatment patterns in patients with dementia-related psychosis. Medicare claims data from 2008 to 2016 were used to identify patients with dementia-related psychosis. The agents and associated dosages prescribed, time to first use, and patterns of use were evaluated for agents prescribed to treat dementia-related psychosis. In total, 49 509 patients were identified as having dementia-related psychosis. Over three-quarters (76.8%) received an antipsychotic or divalproex. The most prescribed first-line agents were quetiapine (30.5%), risperidone (19.5%), and divalproex (11.2%). More than 80% of patients received a low dose of an agent, and 65.5% switched or discontinued their first-line treatment during a mean follow-up period of 1.8 years. In the absence of US FDA-approved therapies to treat dementia-related psychosis, treatment after behavioral intervention involves frequent use of low-dose antipsychotics or divalproex. The high rate of treatment switching or discontinuation is consistent with current treatment guidelines and suggests a need for an improved, standardized pharmacological approach to treat dementia-related psychosis.

Symptoms and Treatment Needs of People with Dementia-Related Psychosis: A Mixed-Methods Study of the Patient Experience

OBJECTIVES

This study describes the person-centered experience and impact of symptoms and the treatment needs of dementia-related psychosis (DRP) from a patient and care partner perspective.

METHODS

Qualitative interviews and a quantitative survey were used to collect patient experience data from persons with DRP or their care partners.

RESULTS

Sixteen participants (1 person with DRP, 15 care partners) completed the qualitative interview; 212 participants (26 persons with DRP, 186 care partners) completed the quantitative survey. The most commonly reported symptoms were visual hallucinations, auditory hallucinations, persecutory delusions, and distortion of senses. The most common impacts were difficulty differentiating what is real from what is not real, increased anxiety, and effects on personal relationships. Current treatments were less than moderately helpful, and the ability to distinguish what is real from what is not real and overall symptom improvement were described as the most important benefits of an ideal treatment.

CONCLUSIONS

Patient experience data provide insights into urgent therapeutic needs of patients by describing the nature, frequency, and severity of symptoms and the impacts they have on individuals' lives.

CLINICAL IMPLICATIONS

Patient experience data demonstrate an unmet need for treatments to reduce the symptoms and impacts of DRP.

Economic Evaluation of Healthcare Resource Utilization and Costs for Newly Diagnosed Dementia-Related Psychosis

This retrospective cohort study described changes in all-cause healthcare resource utilization (HCRU) and associated costs in dementia patients newly diagnosed with psychosis. Dementia and incident psychosis were identified using diagnostic and pharmacy claims using a Medicare 20% random sample dataset. All-cause HCRU and unweighted and weighted (by person-years of follow-up) HCRU-associated costs were evaluated in the year prior to and the 4 years following diagnosis of psychosis. In 49,509 dementia patients with psychosis, physician visits per patient per year increased from a mean of 26.7 (standard deviation (SD) 20.0) prior to psychosis to 38.4 (SD 41.9) post-psychosis diagnosis. The number of inpatient stay claims increased from 1.0 (SD 1.4) to 1.7 (SD 5.8). Mean unweighted costs for inpatient stays and home healthcare/hospice during 2008–2016 were USD 9989 and USD 3279 prior to a diagnosis of psychosis but increased to USD 25,982 and USD 9901 (weighted: USD 11,779 and USD 6709), respectively, in the year after a psychosis diagnosis. This pattern of a sharp increase in mean costs was also observed in costs adjusted to 2015 USD, and in both unweighted and weighted total and psychosis-related costs. These results indicate the importance of identifying newly diagnosed psychosis in dementia patients as well as the pressing need for management strategies and treatments that can reduce HCRU and costs.

Medicare Claims Data Underestimate Hallucinations in Older Adults With Dementia

OBJECTIVE

Administrative claims data are used to study the incidence and outcomes of dementia-related hallucinations, but the validity of International Classification of Diseases (ICD) codes for identifying dementia-related hallucinations is unknown.

METHODS

We analyzed Medicare-linked survey data from 2 nationally representative studies of U.S. older adults (the National Health and Aging Trends Study and the Health and Retirement Study) which contain validated cognitive assessments and a screening question for hallucinations. We identified older adults who had dementia or were permanent nursing home residents, and we combined this with questionnaire responses to define dementia-related hallucinations. Using Medicare claims data, we calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ICD codes for dementia-related hallucinations overall and within prespecified strata of age, neurologic comorbidity, and health care utilization.

RESULTS

We included 2,337 older adults with dementia in our cohort. Among 3,789 person-years of data, 1,249 (33.0%) had hallucations, and of these 286 had a qualifying ICD code for dementia-related hallucinations or psychosis (sensitivity 22.9%). Of 2,540 person-years of dementia without hallucinations, 284 had a diagnosis code for hallucinations (specificity 88.8%). PPV was 50.2%, and NPV was 70.1%. Sensitivity was greatest (57.0%) among those seeing a psychiatrist. Otherwise, there were no significant differences in sensitivity, specificity, PPV, or NPV by age, neurologic diagnosis, or neurologist care.

CONCLUSION

Dementia-related hallucinations are poorly captured in administrative claims data, and estimates of their prevalence and outcomes using these data are likely to be biased.

Development and assessment of a brief screening tool for psychosis in dementia

INTRODUCTION

Hallucinations and delusions (H+D) are common in dementia, but screening for these symptoms-especially in busy clinical practices-is challenging.

METHODS

Six subject matter experts developed the DRP3™ screen, a novel valid tool to detect H+D in dementia, assessed its content validity through alignment with DRP reference assessments (Scale for the Assessment of Positive Symptoms-Hallucinations + Delusions, Neuropsychiatric Inventory-Questionnaire, International Psychogeriatric Association Criteria), and retrospectively investigated its ability to detect H+D in HARMONY trial (NCT03325556) enrollees.

RESULTS

All items from three reference assessments demonstrated significant agreement with the DRP3 screen among raters (P < .0001). Retrospectively applying the DRP3 screen to HARMONY identified all (N = 392) trial enrollees.

DISCUSSION

The DRP3 screen, comprising three yes/no questions, is a content-valid tool for detecting H+D in dementia that aligned with current reference assessments and successfully identified trial participants when retrospectively applied to a completed trial. Within busy practice constraints, the DRP3 screen provides a brief tool for sensitive detection of H+D in patients with dementia.