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Overview of late-onset psychoses
- D.P. Devanand, Dilip V. Jeste, T. Scott Stroup, Terry E. Goldberg
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- Journal:
- International Psychogeriatrics / Volume 36 / Issue 1 / January 2024
- Published online by Cambridge University Press:
- 03 March 2023, pp. 28-42
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Background:
Several etiologies can underlie the development of late-onset psychosis, defined by first psychotic episode after age 40 years. Late-onset psychosis is distressing to patients and caregivers, often difficult to diagnose and treat effectively, and associated with increased morbidity and mortality.
Methods:The literature was reviewed with searches in Pubmed, MEDLINE, and the Cochrane library. Search terms included “psychosis,” “delusions,” hallucinations,” “late onset,” “secondary psychoses,” “schizophrenia,” bipolar disorder,” “psychotic depression,” “delirium,” “dementia,” “Alzheimer’s,” “Lewy body,” “Parkinson’s, “vascular dementia,” and “frontotemporal dementia.” This overview covers the epidemiology, clinical features, neurobiology, and therapeutics of late-onset psychoses.
Results:Late-onset schizophrenia, delusional disorder, and psychotic depression have unique clinical characteristics. The presentation of late-onset psychosis requires investigation for underlying etiologies of “secondary” psychosis, which include neurodegenerative, metabolic, infectious, inflammatory, nutritional, endocrine, and medication toxicity. In delirium, psychosis is common but controlled evidence is lacking to support psychotropic medication use. Delusions and hallucinations are common in Alzheimer’s disease, and hallucinations are common in Parkinson’s disease and Lewy body dementia. Psychosis in dementia is associated with increased agitation and a poor prognosis. Although commonly used, no medications are currently approved for treating psychosis in dementia patients in the USA and nonpharmacological interventions need consideration.
Conclusion:The plethora of possible causes of late-onset psychosis requires accurate diagnosis, estimation of prognosis, and cautious clinical management because older adults have greater susceptibility to the adverse effects of psychotropic medications, particularly antipsychotics. Research is warranted on developing and testing efficacious and safe treatments for late-onset psychotic disorders.
Change in agitation in Alzheimer's disease in the placebo arm of a nine-week controlled trial
- Paul B. Rosenberg, Lea T. Drye, Anton P. Porsteinsson, Bruce G. Pollock, D.P. Devanand, Constantine Frangakis, Zahinoor Ismail, Christopher Marano, Curtis L. Meinert, Jacobo E. Mintzer, Cynthia A. Munro, Gregory Pelton, Peter V. Rabins, Lon S. Schneider, David M. Shade, Daniel Weintraub, Jeffery Newell, Jerome Yesavage, Constantine G. Lyketsos, for the CitAD Research Group
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- Journal:
- International Psychogeriatrics / Volume 27 / Issue 12 / December 2015
- Published online by Cambridge University Press:
- 25 August 2015, pp. 2059-2067
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Background:
Placebo responses raise significant challenges for the design of clinical trials. We report changes in agitation outcomes in the placebo arm of a recent trial of citalopram for agitation in Alzheimer's disease (CitAD).
Methods:In the CitAD study, all participants and caregivers received a psychosocial intervention and 92 were assigned to placebo for nine weeks. Outcomes included Neurobehavioral Rating Scale agitation subscale (NBRS-A), modified AD Cooperative Study-Clinical Global Impression of Change (CGIC), Cohen-Mansfield Agitation Inventory (CMAI), the Neuropsychiatric Inventory (NPI) Agitation/Aggression domain (NPI A/A) and Total (NPI-Total) and ADLs. Continuous outcomes were analyzed with mixed-effects modeling and dichotomous outcomes with logistic regression.
Results:Agitation outcomes improved over nine weeks: NBRS-A mean (SD) decreased from 7.8 (3.0) at baseline to 5.4 (3.2), CMAI from 28.7 (6.7) to 26.7 (7.4), NPI A/A from 8.0 (2.4) to 4.9 (3.8), and NPI-Total from 37.3 (17.7) to 28.4 (22.1). The proportion of CGI-C agitation responders ranged from 21 to 29% and was significantly different from zero. MMSE improved from 14.4 (6.9) to 15.7 (7.2) and ADLs similarly improved. Most of the improvement was observed by three weeks and was sustained through nine weeks. The major predictor of improvement in each agitation measure was a higher baseline score in that measure.
Conclusions:We observed significant placebo response which may be due to regression to the mean, response to a psychosocial intervention, natural course of symptoms, or nonspecific benefits of participation in a trial.
Agitation in cognitive disorders: International Psychogeriatric Association provisional consensus clinical and research definition
- Jeffrey Cummings, Jacobo Mintzer, Henry Brodaty, Mary Sano, Sube Banerjee, D.P. Devanand, Serge Gauthier, Robert Howard, Krista Lanctôt, Constantine G. Lyketsos, Elaine Peskind, Anton P. Porsteinsson, Edgardo Reich, Cristina Sampaio, David Steffens, Marc Wortmann, Kate Zhong
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- Journal:
- International Psychogeriatrics / Volume 27 / Issue 1 / January 2015
- Published online by Cambridge University Press:
- 14 October 2014, pp. 7-17
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Background:
Agitation is common across neuropsychiatric disorders and contributes to disability, institutionalization, and diminished quality of life for patients and their caregivers. There is no consensus definition of agitation and no widespread agreement on what elements should be included in the syndrome. The International Psychogeriatric Association formed an Agitation Definition Work Group (ADWG) to develop a provisional consensus definition of agitation in patients with cognitive disorders that can be applied in epidemiologic, non-interventional clinical, pharmacologic, non-pharmacologic interventional, and neurobiological studies. A consensus definition will facilitate communication and cross-study comparison and may have regulatory applications in drug development programs.
Methods:The ADWG developed a transparent process using a combination of electronic, face-to-face, and survey-based strategies to develop a consensus based on agreement of a majority of participants. Nine-hundred twenty-eight respondents participated in the different phases of the process.
Results:Agitation was defined broadly as: (1) occurring in patients with a cognitive impairment or dementia syndrome; (2) exhibiting behavior consistent with emotional distress; (3) manifesting excessive motor activity, verbal aggression, or physical aggression; and (4) evidencing behaviors that cause excess disability and are not solely attributable to another disorder (psychiatric, medical, or substance-related). A majority of the respondents rated all surveyed elements of the definition as “strongly agree” or “somewhat agree” (68–88% across elements). A majority of the respondents agreed that the definition is appropriate for clinical and research applications.
Conclusions:A provisional consensus definition of agitation has been developed. This definition can be used to advance interventional and non-interventional research of agitation in patients with cognitive impairment.