Once again, IPA has taken the lead to advance the mental health care of older persons using its inclusive process to address the needs of patients and providers around the globe. Psychosis in the presence of cognitive impairment and dementia is a common, distressing, and disabling disorder. Delusions such as the belief that one’s spouse is not who they claim to be or believing that people are stealing one’s belongings and hallucinations including seeing people in one’s home or hearing voices when no one is talking are among the most unsettling aspects of a neurological disorder. This issue of International Psychogeriatrics (1) presents a reprise of the recently published Criteria for Major and Mild Neurocognitive Impairment (2).  This effort – led by the International Psychogeriatric Association (IPA) — re-examined the criteria for psychosis in Alzheimer’s disease published by Dilip Jeste and Sandy Finkel over 20 years ago (3). The criteria have had remarkable durability and have been influential in many types of clinical research and clinical trials. 

During the past 20 years, there has been substantial progress in understanding psychosis as well as evolving concepts of dementia and mild cognitive impairment. A survey of IPA members and members of affiliate organizations, many of whom are clinicians who routinely see and treat these patients called attention to the need to define and provide examples of delusions and hallucinations, define time frames more strictly (e.g., how long must delusions or hallucinations be present to meet the criteria), expand the associated neurological disorders. Respondents also supported providing definitions of severity and duration and impact on care partners.  A comprehensive process with a steering committee, face-to-face meeting (pre-COVID) of international experts, including patient and family advocates and reiterative manuscript development led to the recently published criteria. The revised criteria provide definitions and examples of hallucinations and delusions; use the DSM5 lexicon of major and mild neurocognitive disorder were used to describe the neurological setting of the psychosis; describe time elements such as the requirement for the psychotic symptoms to have been present intermittently for at least one month; and define severity as interfering with the patient’s or other’s ability to accomplish activities of daily living or interact as usual socially.  Exclusionary factors include the presence of delirium or presence of another disorder with psychosis such as schizophrenia.  Also excluded are circumstances where the beliefs may be culturally bound or in conditions where psychosis-like phenomena are known to occur such as visual hallucinations with blindness and auditory hallucinations with deafness.

The expanded definitions are expected to improve their reliability and validity. The intent of the IPA process is to promote excellence in clinical care. These revised criteria will assist in clinical research of all types and can be used to better define participants for clinical trials. Through this effort, the IPA leads in the effort to provide better care to elderly and cognitively compromised individuals.

1.  Sano M, Cummings J, Jeste D, Finkel S, Reichman W.  International Psychogeriatric Association (IPA) Consensus for Defining Psychosis in Major and Mild Neurocognitive Disorder. Internat Psychogeriatr 2021 Online Apr;7:1-5.

2.  Cummings J, Pinto LC, Cruz M, Fischer CE, Gerritsen DL, Grossberg GT, Hwang TJ, Ismail Z, Jeste DV, Koopmans R, Lanctot KL, Mateos R, Peschin S, Sampaio C, Tsuang D, Wang H, Zhong K, Bain LJ, Sano M. Criteria for Psychosis in Major and Mild Neurocognitive Disorders: International Psychogeriatric Association (IPA) Consensus Clinical and Research Definition.  Am J Geriatr Psychiatry. 2020 Dec;28(12):1256-1269.

3.  Jeste DV, Finkel SI.  Psychosis of Alzheimer’s disease and related dementias. Diagnostic criteria for a distinct syndrome.  Am J Geriatr Psychiatry. 2000 Winter;8(1):29-34.