1 / 19

Delusions and Dementia

Delusions and Dementia. Vaughan Bell. Institute of Psychiatry, King’s College London. Outline. Idiopathic psychoses vs psychosis in dementia Neuropsychology Impact and clinical correlates Treatments: drug and non-drug Conclusions. Early Onset Psychosis.

channer
Download Presentation

Delusions and Dementia

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Delusions and Dementia Vaughan Bell Institute of Psychiatry, King’s College London

  2. Outline • Idiopathic psychoses vs psychosis in dementia • Neuropsychology • Impact and clinical correlates • Treatments: drug and non-drug • Conclusions

  3. Early Onset Psychosis • More males than females, high genetic loading, weakly associated with cognitive impairment. • Most common delusions (Appelbaum et al., 1999) • Persecutory (51.1%) • Body / mind control (26.5%) • Grandiose (23%) • Religious (18%) • Thought broadcasting (6%)

  4. Late / Very Late Onset Psychosis • More females than males, low genetic loading, weakly associated with cognitive impairment. • Most common delusions (Howard et al., 1993) • Persecutory (93.3%) • Passivity (17.2%) • Grandiose (14.9%) • Note also that ‘partition’ delusions and ‘phantom boarder’ delusions are also reported as common (Hassett, 2005)

  5. Delusions in Dementia • No consistent sex difference, virtually no genetic loading, strongly associated with cog. impairment. • Most common delusions (Ballard et al., 1995) • Reference (22%) • Theft or hidden possessions (22%) • Phantom boarder (21%) • Persecution (17.7%) • Misidentification (14.5%) • NB: Other reviews have put persecutory as most prevalent.

  6. Delusions in Dementia • Interestingly, molecular genetic studies have suggested specific risk markers for delusions. • Zdanys et al. (2006) reported ApoE ε4 allele carriers at higher risk specifically for delusions in AD. • This is not a gene identified in mol. genetic studies of idiopathic psychosis. • ApoE ε4also increases risk for AD, younger onset of AD but seemingly not cognitive decline in AD.

  7. Prevalence and Incidence (Prob. AD) • Prevalence: Bassiony and Lyketos (2003) • Clinic sample: 16% - 70% (median 36.5%) • Population: 15% - 22% • Incidence: Devanand et al. (1997) • 6 month transition probability of 17%

  8. Cumulative Incidence (Prob. AD) Cumulative % of delusions by year after diagnosis Paulsen et al. (2000)

  9. Functional Neuroanatomy • Neuroimaging studies on dementia typically implicate right frontal dysfunction. • There seems to be less temporal involvement than in the idiopathic psychoses.

  10. Functional Neuroanatomy • Some suggestion of theme linked to regional changes. Resting PET - Sultzer et al. (2003) Healthy AD No Delusions AD Delusions

  11. Cognitive and Clinical Correlates • Cognitive decline, particularly executive deficits, have been linked with psychosis in AD (Schneider and Dagerman, 2004) • …although is not consistently linked with psychosis in dementia per se (Bassiony and Lyketos, 2003) • However, delusions in AD predict aggression, wandering, functional impairment, worse general health and more severe depression. • Possibly as 1/3 of patients with psychotic dementia show marked distress (Ballard et al., 1995)

  12. Pharmacological Treatment

  13. Pharmacological Treatment • One third of all atypical antipsychotic prescriptions are written for elderly people in long-term care (Schneider, 2002). • Significant adverse effects reported with atypical antipsychotics (Schneider et al., 2006) • Typicals and atypicals associated with increased short-term mortality in dementia (Triforo et al., 2006) • Risperidone is considered most effective (Fischer et al., 2006) • And patients taking antipsychotics are no more likely to decline cognitively (Livingston et al., 2006).

  14. Pharmacological Treatment • Interestingly, donepezil seems to operate as an effective ‘antipsychotic’ (Cummings et al., 2006) • Again, suggesting a strong link between cognitive decline and psychosis. • Which doesn’t seem to be so apparent in idiopathic psychosis.

  15. Nonpharmacological Treatment • “These results and the evidence that behavioral problems in Alzheimer’s disease can be reduced by specialized care that stresses nonpharmacologic management suggest that these drugs have a limited, but at times necessary, role in the care of patients with Alzheimer’s disease” • Karlawish (2006) • There are many studies, and many approaches, but very little adequately executed research into efficacy (Cohen-Mansfield, 2001)

  16. Nonpharmacological Treatment • A recent review (Ayalon et al., 2006) only included systematic studies of sufficient quality. • A grand total of 3 RCTs and 6 single case studies! • Identified three main approaches for neuropsychiatric symptoms: • Unmet needs (i.e. functional analysis approach) • Learning / behavioural interventions • Environmentalvulnerability / stress threshold • All approaches were deemed “possibly efficacious, pending replication of findings”.

  17. Nonpharmacological Treatment • For delusions specifically, the advice is similar for delusions from idiopathic psychosis (Rabins, 1994): • Reassurance • Distraction • Discussing other matters • Discussing feelings behind the delusion

  18. Conclusions • Delusions present differently in dementia. • They are common, and increase over time. • They are associated with significant distress and behaviour disturbance. • They are strongly associated with cognitive decline. • Pharmacotherapy is moderately effective but risky. • Psychological therapy is less risky, promising, but largely untested.

More Related