Guide to the Management of Psychotic Disorders and Neuropsychiatric Symptoms of Dementia in Older Adults
 
GUIDE to the MANAGEMENT of PSYCHOTIC DISORDERS and NEUROPSYCHIATRIC SYMPTOMS of DEMENTIA in OLDER ADULTS
From the American Geriatrics Society  

This guide has been developed to assist healthcare providers in managing psychotic symptoms and disorders in older adults. It is based on two publications of the American Geriatrics Society (AGS) (www.americangeriatrics.org), the 2013 (pre-production) editions of The Geriatrics Review Syllabus and Geriatrics At Your Fingertips.TM.

This guide was reviewed by a panel of AGS members representing geriatric medicine, geropsychiatry, and geriatric pharmacy. The guide was then reviewed and approved by the AGS Executive Committee in October 2012.

We encourage readers to consult the publications listed in the References Section at the end of this guide for a more in-depth discussion of the information contained here, including evidence concerning the increased incidence of mortality in the use of antipsychotic medications in the treatment of behavioral and psychological symptoms associated with dementia.

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Management of Psychotic Disorders in Older Adults


KEY POINTS  

  • Psychotic symptoms are defined as either hallucinations or delusions. Hallucinations are perceptions without stimuli. Delusions are fixed, idiosyncratic, or false perceptions or beliefs with little if any basis in reality and are not the result of religious or cultural norms.
  • Hallucinations can occur in any sensory modality (ie, visual, auditory, tactile, olfactory, gustatory). In late life, multimodal hallucinations are common.
  • Delusions are unfounded ideas that can be suspicious (paranoid), grandiose, somatic, self-blaming, or hopeless. Delusions in late life are often paranoid or persecutory, such as a belief that one’s safety is in jeopardy or that one’s belongings are being stolen.
  • When psychotic symptoms arise in the context of depression or bipolar disorder, the symptoms are often “mood congruent,” eg, in depression, delusions that one is penniless or that one is already dead; in mania, grandiose delusions, elevated self-regard.
  • Psychosis occurring for the first time in late life is often due to dementia or neurologic conditions such as Parkinson’s disease or stroke, as opposed to a primary psychotic disorder, such as schizophrenia.

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DIFFERENTIAL DIAGNOSIS  

  • Bipolar disorder: Grandiose and/or paranoid delusions can be seen in the manic phase of bipolar disorder. Other prominent symptoms include decreased need for sleep, increased goal-directed activity, increased rate of speech
  • Delirium: Hallucinations, particularly visual hallucinations, can be a symptom of delirium, even when it is mild. The onset of delirium is typically acute, and there is usually an identifiable metabolic, pharmacologic, or infectious cause. The mental status examination reveals multiple cognitive impairments and a diminished or waxing and waning level of consciousness. Generalized slowing on electroencephalography could also help in differentiating delirium from other conditions.
  • Dementia: Alzheimer disease with prominent frontal symptoms or frontotemporal dementia can be confused with late-onset schizophrenia, as it can involve features of socially inappropriate, objectionable, and odd behaviors as well as premorbidly odd or “schizoid” personality features. Lewy body dementia usually presents with visual hallucinations in the context of autonomic instability, parkinsonism, and frequent falls.
  • Medications/drugs: eg, anticholinergics, antiparkinsonian agents, benzodiazepines or alcohol (including withdrawal), cardiac medications (eg, digitalis), corticosteroids, opioid analgesics, stimulants.
  • Late-onset delusional (paranoid) disorder or late onset schizophrenia.
  • Major depression: Delusions in major depressive disorder usually reflect self-deprecation, self-blame, hopelessness, or the conviction of ill health.
  • Physical disorders: hypo- or hyperglycemia, hypo- or hyperthyroidism, sodium or potassium imbalance, Cushing’s syndrome, Parkinson’s disease, B12 deficiency, sleep deprivation, AIDS
  • Pain, untreated
  • Schizophrenia
  • Structural brain lesions: tumor or stroke
  • Seizure disorder: eg, temporal lobe

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RISK FACTORS FOR PSYCHOTIC SYMPTOMS IN OLDER ADULTS  

  • Chronic bed rest
  • Cognitive impairment
  • Female gender
  • Sensory impairment
  • Social isolation

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SCHIZOPHRENIA AND SCHIZOPHRENIA-LIKE SYNDROMES  

  • Schizophrenia is characterized by positive symptoms (eg, hallucinations, delusions, and thought disorder) and negative symptoms (eg, social dilapidation and apathy), and cognitive deficits.
  • Approximately 85% of older adults with schizophrenia experienced onset of illness in early adult life. However, 10%–15% of cases of schizophrenia first come to clinical attention after age 45.
  • Schizophrenia with onset between ages 40 to 60 is called “late-onset schizophrenia.” Onset after age 60 is considered “very-late-onset schizophrenia-like psychosis.”
  • Late-onset schizophrenia-like conditions are characterized by prominent persecutory (paranoid) delusions and multimodal hallucinations manifesting as complaints, eg, items are being stolen or a neighbor is persistently banging on the walls or roof.
  • A schizophrenia-like psychosis can be diagnosed only when cognitive disorder, mood disorder, or other explanatory medical conditions such as delirium or focal brain pathology have been excluded (see Figure 1).
  • The schizophrenia-like psychoses of late life differ from schizophrenia beginning in early life in two ways:
    • Thought disorder (eg, speech in which a series of thoughts are not connected to one another in a logical fashion) is much less common in older adults. When illogical speech occurs in late life, delirium or dementia should be excluded.
    • Social deterioration and dilapidation is rare among older adults; personality is often intact in late-onset cases.
    • Late-onset schizophrenia is more common among women than men.
  • Many individuals with schizophrenia experience fewer hallucinations and delusions as they age, others remain significantly functionally impaired by psychotic symptoms or may experience further deterioration.
  • Cognitively, older individuals with schizophrenia experience similar age-associated declines as those without schizophrenia. A subgroup of individuals with schizophrenia may experience accelerated decline, particularly if they have been chronically institutionalized.
  • Older adults with schizophrenia have an increased risk of suicidal behavior compared with that of their peers without mental illness.

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TREATMENT AND MANAGEMENT OF SCHIZOPHRENIA AND SCHIZOPHRENIA-LIKE SYNDROMES  

  • Establish a trusting therapeutic relationship with the patient; focus on empathizing with the distress that symptoms cause rather than reality orientation.
  • Encourage patients to maintain significant, supportive relationships.
  • Alleviate underlying physical causes.
  • Address identifiable psychosocial triggers.
  • Before using antipsychotic to treat behavioral symptoms for dementia, carefully assess for possible psychotic features (ie, delusions and hallucination and if psychotic symptoms are severe, frightening, or may affect safety.
  • Aripiprazole, risperidone and ziprasidone are first choice, followed by the more anticholinergic drugs; olanzapine and quetiapine. These drugs have fewer adverse events (tardive dyskenesia [TD] extremely high in older adults taking first-generation antipsychotics).
  • All antipsychotics are associated with increased mortality in older adults.
  • See Table 1 for representative medications for treatment of schizophrenia or schizophrenia-like syndromes, Table 2 for adverse events of second-generation antipsychotics, and Table 3 for management of adverse events of antipsychotic medications.

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PSYCHOTIC DISORDER CAUSED BY A GENERAL MEDICAL CONDITION  

PARKINSON'S DISEASE

  • Psychotic symptoms may be secondary to a prescribed dopaminergic agent, but some patients experience visual hallucinations before any medications are started. Education and support should be offered to all patients with these symptoms. If the patients experience significant emotional distress or if the symptoms lead to dangerous or upsetting behavior, cautious use of an antipsychotic medication is appropriate
    (see Table 1).
  • For patients with Parkinson’s disease and hallucinations, quetiapine 12.5–75 mg/d or olanzapine 2.5–5 mg/d may be beneficial. Some patients require clozapine 12.5–75 mg/d. However, patients taking clozapine must have a CBC done once a week for 6 mo and then biweekly thereafter because of the risk of granulocytopenia.

LEWY BODY DEMENTIA

  • Dementia associated with Lewy bodies is increasingly recognized as an important cause of hallucinations in late life. The clinical scenario typically involves cognitive decline accompanied by motor features of parkinsonism. However, prominent visual hallucinations are a key part of the diagnosis. These hallucinations are often vivid and troubling.
  • Dementia associated with Lewy bodies presents a challenge similar to that of psychosis in Parkinson’s disease, because antipsychotic medications worsen the parkinsonian symptoms. No trial data are available to guide medication choice, but there are case reports of significant improvement through the use of cholinesterase inhibitors, and one positive randomized placebo-controlled trial with rivastigmine (Grace, et al).

If an antipsychotic medication must be used, then the treatment strategies outlined for Parkinson’s disease are appropriate if there is careful attention to the risk of extrapyramidal adverse events. Nonpharmacologic treatments include redirection, reassurance, and explanation.

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SUBSTANCE-INDUCED PSYCHOTIC DISORDER  

  • Many classes of medications are associated with psychotic adverse events. Older adults are particularly vulnerable, especially those with CNS impairments.
  • Psychotic symptoms have also been reported related to treatment with other medications including: antiarrhythmic agents, antineoplastic agents, antiviral agents, baclofen, ß-blockers, cyclosporine, dopaminergic agents, interferon, opioids, and steroids. The appropriate therapeutic management is to reduce the dosage of or to eliminate the associated medication.

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Management of Neuropsychiatric Symptoms of Dementia


KEY POINTS  

  • The development of behavioral disturbances or neuropsychiatric symptoms (NPS) in dementia often precipitates early nursing-home placement and causes significant caregiver burden and distress.
  • Behavioral symptoms in dementia require evaluation of the specific symptoms, the patient’s comfort, the care environment, the needs of the caregiver, and the degree of distress of all those involved in the life of the older adult with dementia.
  • Delirium secondary to an underlying condition such as dehydration, urinary tract infection, medication toxicity, or pain is a common cause of abrupt behavioral disturbances in patients with dementia.
  • Medication treatment of behavioral disturbances in dementia is of limited efficacy and should be used only after environmental and nonpharmacologic techniques have been implemented.
  • No psychoactive medication prescribed to treat NPS of dementia should be continued indefinitely, and attempts at drug withdrawal should be made regularly (eg, every 3-6 months).
  • Increased mortality has been identified with the use of both first- and second-generation agents. All antipsychotic agents now carry an FDA warning regarding increased all-cause mortality in patients with dementia.
  • Despite these FDA warnings, antipsychotic medications may be needed for treatment of distressing delusions and hallucinations, and antidepressants may be helpful if symptoms of depression are evident. There is some evidence for considering mood stabilizers for symptoms such as impulsivity and aggression in patients who have significant behavioral disturbances.
  • When using any antipsychotic medication for any patient, and particularly when using them for an off-label indication, it is prudent to include in the informed consent process a mention of the possible association of treatment with increased mortality among patients with dementia, in addition to the other potential adverse effects, such as cerebrovascular events or metabolic syndrome. It is also advisable to document the process of informing the family member and, if capable, the patient of the future risk of mortality, stroke, and metabolic syndrome weighed against the present risk posed by the psychosis.
  • Treatment of psychiatric and behavioral disturbances in dementia is complex and may require several interventions as part of a comprehensive care plan. The goal is reduction rather than elimination of the distressing behavior. In refractory cases, a specialist, such as a geriatric psychiatrist, geriatrician, or neurologist with specific expertise in the pharmacologic treatment of the neuropsychiatric symptoms of Alzheimer’s disease, should be consulted.

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COMMON NEUROPSYCHIATRIC SYMPTOMS ASSOCIATED WITH DEMENTIA  

PSYCHOTIC SYMPTOMS (DELUSIONS, HALLUCINATIONS)

  • Seen in about 20% of Alzheimer’s disease (AD) patients
  • Delusions may be paranoid (eg, people stealing things, spouse unfaithful)
  • Hallucinations (~11% of patients) are more commonly visual
  • See Table 1 for antipsychotic medications for the treatment of psychosis in dementia.

DEPRESSIVE SYMPTOMS

  • Seen in up to 40% of AD patients; may precede onset of AD
  • Signs include sadness, loss of interest in usual activities, anxiety, and irritability
  • Suspect if patient stops eating or withdraws
  • May cause acceleration of decline if untreated
  • Recreational programs and activity therapies have shown positive results
  • See Table 4 for medications most commonly used to treat depressive features of behavioral disturbances in dementia; first-line agents are SSRIs, preferred for more favorable adverse-event profiles.

APATHY

  • High prevalence and persistence throughout course of AD
  • Causes more impairment in Activities of Daily Living than expected for cognitive status
  • High overlap with depressive symptoms but lacks depressive mood, guilt, and hopelessness

MANIC-LIKE BEHAVIORAL SYNDROMES

  • Characterized by pressured speech, disinhibition, elevated or irritable mood, intrusiveness, hyperactivity, impulsivity, reduced sleep
  • Frequent co-occurrence with confusional states
  • See Table 5 for mood stabilizers for behavioral disturbances in dementia with manic-like features.

AGITATION OR AGGRESSION

  • Seen in up to 80% of patients with Alzheimer’s disease
  • A leading cause of nursing-home admission
  • Identify and examine context of behavior (is it harmful to patient or others?) and environmental triggers (eg, overstimulation, unfamiliar surroundings, frustrating interactions).
  • Determine whether delusions or hallucinations are interfering with function.
  • Exclude underlying physical discomfort (eg, pain or hunger).
  • Always consider nonpharmacologic strategies first:
    Advise caregiver(s) to:
    • Use scheduled toileting and prompted toileting for incontinence.
    • Offer graded assistance (as little help as possible to perform ADLs), role modeling, cueing, and positive reinforcement to increase independence.
    • Avoid adversarial debates; try to redirect conversation instead.
    • Maintain a calm demeanor.
    • Use services of caregiver support groups.
    For problem behaviors:
    • Music during meals, bathing
    • Walking or light exercise
    • Simulate family presence with video or audio tapes
    • Pet therapy
    • Speak at patient’s comprehension level
    • Bright light, “white” noise (ie, low-level, background noise)
  • For intermittent disruptive behaviors (once per week or less), identifying antecedents of the behavior and avoiding triggers is often most useful. Behavior modification using positive reinforcement of desirable behavior has been shown to be effective, and also helps caregiver focus on times when behavior is not a problem.
  • Physical restraint in any form should be avoided if at all possible. If restraining measures are necessary, careful supportive care should be provided to the patient. Over time, it is usually possible to reduce or eliminate the amount of restraint.
  • Select pharmacologic agent on the basis of symptoms (see Table 6).
    • Cognitive enhancers may slow deterioration, and agitation may worsen if they are discontinued.
    • Low dosages of antipsychotic medications have a limited role but may be necessary at times. Note: this use is “off label; ”use in AD patients has a BLACK BOX warning because the risk of death was higher with drug treatment than with placebo in clinical trials. Risk–benefit must be discussed with patients, surrogate decision-makers, families, and/or caregivers before starting treatment (see Studies regarding excess mortality associated with antipsychotic medication use in patients with dementia, and References).

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SUMMARY OF STUDIES  

SUMMARY OF STUDIES REGARDING EXCESS MORTALITY ASSOCIATED
WITH ANTIPSYCHOTIC MEDICATION USE IN PATIENTS WITH DEMENTIA
(See also References)


On April 12, 2005, the U.S. Food and Drug Administration (FDA) issued a public health advisory on a newly identified concern associated with the off-label use of second-generation (atypical) antipsychotic medications for the treatment of dementia-related behavioral disorders in older adults. This advisory, based on an FDA analysis of data from 17 randomized, controlled trials that enrolled 5377 older adults with dementia-related behavioral disorders, showed that the risk of death in the drug-treated patients was 1.6–1.7 compared with that of the placebo group. Treatments consisted of aripiprazole, olanzapine, quetiapine, or risperidone. These trials averaged about 10 weeks. The rate of death was about 4.5% in drug-treated patients and about 2.6% in the placebo group. Most of the deaths appeared to be either cardiovascular (eg, heart failure, sudden death) or infectious (eg, pneumonia) in nature.

Several studies, summarized in a Cochrane Review and in a systematic review published in the Journal of the American Medical Association (JAMA) cite the clinically modest but significant reductions in NPS demonstrated among elderly subjects treated with olanzapine or risperidone. To date, while some efficacy has been noted in published placebo-controlled trials conducted with non-antipsychotic medications such as carbamazepine, citalopram, donepezil, galantamine, or memantine, this data is even more limited than that of the second-generation antipsychotics.

There has also been evidence published from an extensive Centers for Medicare and Medicaid (CMS) database that second-generation antipsychotic medications, compared to first-generation (typical) antipsychotics, do not appear to be associated with an increased risk of ventricular arrhythmias or cardiac arrest.

Two observational epidemiological studies were published that examined the risk of death in patients who were treated with first-generation antipsychotic medications:

  • Gill, et al, performed a retrospective cohort study in Ontario, Canada of 27,259 adults, 66 years of age or older, with a diagnosis of dementia between April 1997 and March 2002. The investigators compared the risk for death with use of a second-generation antipsychotic versus no antipsychotic and the risk for death with use of a first-generation antipsychotic versus a second-generation antipsychotic. They found that second-generation antipsychotics were associated with increased mortality as compared to no antipsychotic use as early as 30 days and persisting until study end at 180 days. The investigators found that first-generation antipsychotic use showed a marginally higher risk of death compared with second-generation antipsychotic use. The causes of death were not reported in this study.
  • Schneeweiss, et al, performed a retrospective cohort study in British Columbia, Canada of 37,241 adults, 65 years of age or older, who were prescribed first-generation (12,882) or second-generation (24,359) antipsychotic medications for any reason between January 1996 and December 2004. The investigators compared the 180-day all cause mortality with use of a first-generation antipsychotic versus a second-generation antipsychotic. They found that the risk of death in the group of patients treated with first-generation antipsychotic medications was comparable to, or possibly greater than, the risk of death in the group of patients treated with second-generation antipsychotic medications. The causes of death with the highest relative risk were cancer and cardiac disease.

The FDA considers that the methodological limitations in these two studies preclude any conclusion that first-generation antipsychotics have a greater risk of death with use than second-generation antipsychotics. The FDA has determined, however, that the overall weight of evidence indicates that first-generation antipsychotics share the increased risk of death in elderly patients with dementia-related psychosis that has been observed for second-generation antipsychotics. Therefore, the prescribing information for all antipsychotic drugs now includes the same information about this risk in a Boxed Warning and the Warnings section.

A recent five-year retrospective study by Rossom, et al, using U.S. Veterans Administration data from more than 89,000 veterans did not find an increased risk of death in veterans with dementia who were prescribed lower doses of olanzapine (<2.5 mg/d), quetiapine (<50 mg/d), or risperidone (<1 mg/d). However, at typically prescribed doses, second-generation antipsychotics (excluding quetiapine) were associated with an increased risk of death. All doses of haloperidol were associated with increased mortality.

The mechanism(s) for increased mortality associated with antipsychotic use remain uncertain and needs careful examination. One study approaching this problem comes from another recent large epidemiological five-year retrospective nested case-control study of primary care patients in the United Kingdom, by Parker, et al. They found that there was a 32% greater risk for venous thromboembolism (VTE) in those prescribed antipsychotics in the previous 24 months vs non–antipsychotic users. The risk was even greater for new users and for those taking second-generation antipsychotics. The study examined risks by type of antipsychotic, potency and dose, and adjusted for comorbidity and concomitant drug exposure. A total of 25,532 "eligible cases" were selected for this study and a total of 89,491 matched healthy controls were also included. The median age for all participants was 67 years. Understanding mechanisms for adverse events leading to mortality should allow risk profiling of patients and eventually lead to approaches to minimize risk in those patients who otherwise need and benefit from this therapy.

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REFERENCES  

CLINICAL REFERENCES USED IN THE DEVELOPMENT OF THIS GUIDE

Lantz MS, Khanmohamadi A, Wong PY. Behavioral problems in dementia. In: Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 8th ed. New York: American Geriatrics Society; 2013 (forthcoming).

Lehmann SW. Psychotic disorders. In: Pacala JT, Sullivan GM, eds. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine. 8th ed. New York: American Geriatrics Society; 2013 (forthcoming).

Lyketsos CG, Colenda CC, Beck C, et al. Task Force of American Association for Geriatric Psychiatry. Position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from Alzheimer disease. Am J Geriatr Psychiatry 2006;14:561-72.

Reuben DB, Herr KA, Pacala JT, Pollock BG, Potter JF, Semla TP. Dementia. In: Geriatrics At Your Fingertips: 2013.15th ed. New York: The American Geriatrics Society; 2013 (forthcoming).

Reuben DB, Herr KA, Pacala JT, Pollock BG, Potter JF, Semla TP. Psychotic disorders. In: Geriatrics At Your Fingertips: 2013.15th ed. New York: The American Geriatrics Society; 2013 (forthcoming).

REFERENCES REGARDING THE USE OF ANTIPSYCHOTIC MEDICATIONS IN PATIENTS WITH DEMENTIA

Brodaty H, Ames D, Snowdon J, et al. A randomized placebo-controlled trial of risperidone for the treatment of aggression, agitation, and psychosis of dementia. J Clin Psychiatry 2003; 64:134-43.

De Deyn PP, Rabheru K, Rasmussen A, et al. A randomized trial of risperidone, placebo, and haloperidol for behavioral symptoms of dementia. Neurology 1999;53:946–955.

Gill SS, Bronskill SE, Normand SL, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med 2007;146:775-786.

Grace J, Daniel S, Stevens T, et al. Long-term use of rivastigmine in patients with dementia with Lewy bodies: An open-label trial. Int Psychogeriatr 2001;13:199-205.

Katz IR, Jeste DV, Mintzer JE, et al. Comparison of risperidone and placebo for psychosis and behavioral disturbances associated with dementia: A randomized, double-blind trial. J Clin Psychiatry 1999;60:107-15.

Liperoti R. Gambassi G. Lapane KL, et al. Conventional and atypical antipsychotics and the risk of hospitalization for ventricular arrhythmias or cardiac arrest. Arch Intern Med 2005;165:696-701.

Parker C, Coupland C, Hippisley-Cox J. Antipsychotic drugs and risk of venous thromboembolism: nested case-control study. BMJ 2010;341:c4245 doi:10.1136/bmj.c4245 (online .pdf accessed Oct 25, 2010).

Rossom RC, Rector TS, Lederle FA, et al. Are all commonly prescribed antipsychotics associated with greater mortaility in elderly male veterans with dementia? J Am Geriatr Soc 2010;58:1027-34.

Schneeweiss S, Setoguchi S, Brookhart A, et al. Risk of death associated with the use of conventional versus atypical antipsychotic drugs among elderly patients. CMAJ 2007;176:627-632

Schneider LS, Tariot PN, Dagerman MS, et al, for the CATIE-AD Study Group. Effectiveness of atypical antipsychotic drugs in patients and Alzheimer’s disease. New Engl J Med 2006;355:1525-1538.

Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA 2005;293:596-608.

Street JS, Clark WS, Gannon KS, et al. Olanzapine treatment of psychotic and behavioral symptoms in patients with Alzheimer disease in nursing care facilities: A double-blind, randomized, placebo-controlled trial. The HGEU Study Group. Arch Gen Psychiatry 2000;57:968-76.

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