Psychosis in Dementia

Aka: Psychosis in Dementia, Dementia with Comorbid Psychosis

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II. Epidemiology

  1. Incidence in Alzheimer's Disease: 50%

III. Symptoms: Positive

  1. Hallucinations
    1. Visual (most common)
    2. Phantom Border Syndrome
      1. Unseen person living in home
  2. Delusions
    1. Patient believes items are being stolen
    2. Patient believes they must go to work
    3. Capgras' Syndrome
      1. Patient suspects care givers are imposters
  3. Thought disorders
    1. Incoherent
    2. Tangentiality
  4. Disorganized behavior

IV. Symptoms: Negative

  1. Anhedonia
  2. Flat affect
  3. Apathy
  4. Social withdrawal

V. Differential Diagnosis

  1. Schizophrenia
  2. Primary Mood Disorder (Major Depression)
  3. Substance Abuse, Intoxication or withdrawal
  4. Delirium
  5. Parkinson's Disease
  6. Dementia
  7. Intracranial lesion
  8. Cerebrovascular Accident
  9. Subdural Hematoma

VI. Management: General

  1. Indications for management
    1. Psychosis Causes fear or unwanted behavior
    2. Psychosis less commonly causes Agitation, aggression
  2. Behavioral Techniques
    1. Distraction
    2. Reorient with familiar objects, verbal cues, calendar
    3. Redirection
    4. Gentle face-saving confrontation
    5. Maintain sleep-wake cycle

VII. Management: Medications (Neuroleptics)

  1. General
    1. Indicated for failed behavioral techniques
    2. Start with low dose but high potency agents
    3. Give medications on scheduled dosing (Not prn)
  2. Efficacy
    1. Patient will still experience psychotic symptoms
    2. Medication goal is to reduce associated behaviors
      1. Fear
      2. Agitation
    3. Attempt Medication Withdrawal after 3 months
  3. Precautions
    1. No Antipsychotics are FDA approved for Dementia
    2. Atypical Antipsychotics increase mortality risk
      1. FDA issued a black-box warning on Antipsychotics
      2. Associated with increased Cardiovascular Risk
  4. Neuroleptic Preparations
    1. Typical Antipsychotics (Extrapyramidal Side Effects)
      1. Haloperidol (Haldol) 0.5-3.0 mg qd
      2. Thiothixene (Navane) 1.0-6.0 mg qd
      3. Thioridazine (Mellaril)
    2. Atypical Antipsychotics (less adverse effects)
      1. Exacerbate Parkinson's Disease movement
        1. Risperidone (Risperdal) 0.25 - 3.0 mg qd
        2. Avoid Olanzapine
          1. Not recommended in the elderly
          2. Higher risk of CVA and overall mortality
      2. Do not exacerbate Parkinson's Disease
        1. Quetiapine (Seroquel) 12.5 - 200 mg qd
        2. Clozapine 6.5 - 75 mg qd
  5. Adverse Effects: Extrapyramidal
    1. Akathisia (motor restlessness)
    2. Akinesia
    3. Pseudo-Parkinson's Symptoms
      1. Avoid Cogentin or Artane
      2. Associated Anticholinergic effects
        1. Decreased cognitive function
        2. Dry Mouth
        3. Urinary Retention
  6. Adverse effects: Other
    1. Hyperglycemia (screen Blood Sugar every 6 months)

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