Objective: Psychotic features in Alzheimer’s disease (AD) are common phenomena. However, we still have a poor understanding of the natural course of these symptoms and their biologic correlates. The relationship of particular forms of emerging psychotic symptoms to memory impairment and disease progression has been under investigated.
Design: An observational study of psychotic symptoms in AD subjects in different stages of the disease was conducted by means of the use of Neuropsychiatric Inventory (NPI) powered by a series of specific questions addressing other types of delusional ideations (including those encountered in schizophrenia), hallucinatory-like phenomena (misperceptions) and misidentifications which are not specified in NPI.
Materials and Methods: 129 consecutive patients diagnosed as suffering from AD according to NINCSD-ADRDA and DSM-IV criteria (80 female, mean age: 76.8±5.4 yrs, mean MMSE 16.4±4.3) were analyzed for the presence of psychotic symptoms. Delusions, hallucinations and other psychotic phenomena were noted. Demographic data, Mini Mental State Exam (MMSE) and Clinical Dementia Rating (CDR) scores were used as correlates.
Results: Psychotic features of any type were occurring often in our sample with delusions of any type (60% of subjects) being most frequent. Frequency of particular symptoms versus dementia severity analysis revealed the existence of two clusters of phenomena: the related or non-related to dementia severity. The non-related cluster included symptoms that might not be instuitionally associated with memory disturbance (e.g. persecutory delusions, delusions of reference or auditory hallucinations); the frequency of these symptoms was low and comparable in different dementia severity groups. On the other hand the dementia severity related cluster involved symptoms overtly associated with memory disturbance (like delusions that things are being stolen or thinking a patient is not at his/her own home) and occurred mainly in the moderately advanced dementia (a bell shaped correlation between frequency and MMSE score).
Conclusion: AD-associated psychosis is a distinct and heterogeneous phenomenological syndrome and the most commonly used instrument for its clinical assessment (NPI) does not truly appreciate it. We propose a novel classification of psychotic features of dementia including delusions, memory-related delusional ideations, hallucinations, misperceptions and misidentifications that, to our understanding, might smooth the progress of clinical trials in AD. I hypothesize that cholinesterase inhibitors alone might be useful in some clinical situations while in others (memory non-related psychotic features) antipsychotic drug should be the first choice.
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