Nina Vadiei, PharmD and Jeannie Lee, PharmD, College of Pharmacy, University of Arizona

April 2018

Psychotic symptoms occur at some point in as many as 23% of older adults. Most of these individuals have secondary psychosis (i.e., the psychotic symptoms are associated with an underlying medical, psychiatric, or neurological disorder). Examples of underlying causes include dementia and other neurocognitive disorders, delirium, mood disorders, and medical illness. Sometimes, psychosis is due to medications or nutritional supplements.

Most commonly, however, psychosis in older adults is associated with dementia. Psychosis in these instances is less often characterized by clear-cut psychotic symptoms such as delusional ideation or hallucinosis but rather, inferred from grossly disorganized behaviors. This Elder Care will focus primarily on treatment of dementia-associated psychosis. Treatment poses a challenge because there are no medications that reverse the course of dementia.

Management Goals

Psychotic symptoms in demented patients typically come to clinicians' attention because of disruptive behaviors. The goal of treatment is to contain such behaviors, especially when they pose a risk to the patient or others. The first line of treatment is non-pharmacologic. This includes minimizing sensory deficits; addressing possible contributing factors such as pain and constipation; creating a structured, predictable environment; and, importantly, modifying or discontinuing any concurrent medications that might cause or aggravate psychosis, such as certain drugs prescribed for Parkinson's disease. Ultimately, however, pharmacologic approaches are often needed. These rely, to date, primarily on antipsychotics, and these drugs can have serious side effects (Table 1).

All antipsychotics now carry a black-box warning of a 1-2% increased risk of sudden death when given to older adults with dementia. The increased risk of death is primarily due to cerebrovascular events. Thus, before prescribing an antipsychotic, clinicians should assess whether the potential benefit of treatment (e.g., preventing injury to the patient or others) outweighs the risk. Medications should not be prescribed simply to control behavior for the convenience of caretakers or staff.

It is also important to distinguish the type of dementia. Patients with Lewy body dementia are at increased risk of serious side-effects from antipsychotic treatment. Patients with vascular dementia may have more risk of adverse cardiovascular effects, particularly when taking antipsychotics that have an intermediate-to-high metabolic risk (Table 2).

Pharmacotherapy

The first-line, evidence-based psychopharmacologic treatment of disruptive behaviors in dementia should include acetylcholinesterase inhibitors (ACEIs - donepezil, rivastigmine, and galantamine) and memantine. ACEIs (especially donepezil) and memantine have been shown to reduce behavioral symptoms in dementia. Since they have a more favorable safety profile than antipsychotics, they should be tried first.

If ACEIs and memantine fail, second-generation antipsychotics that have shown efficacy in treating disruptive behaviors in dementia are the next choice. Selection of the agent should be based on side-effect profiles (Table 3), as well as the patient's comorbidities. Dosing should start low and be titrated slowly since older adults are more sensitive to side-effects. Target doses are typically lower than those used for younger patients with primary psychotic disorders (Table 4).

Antidepressants, especially SSRIs such as citalopram and sertraline, can reduce behavioral disturbances associated with dementia if there are no psychotic symptoms. They are safer than antipsychotics, but the lag time until improvement is longer. The benefits of other mood stabilizers and other psychotropic agents are currently unclear.

References and Resources

• Colijn MA, Nitta BH, Grossberg GT. Psychosis in Later Life: A Review and Update. Harv Rev Psychiatry. 2015;23(5):354-67.
• Correll CU. From receptor pharmacology to improved outcomes: individualizing the selection, dosing, and switching of antipsychotics. Eur Psychiatry. 2010;25(Suppl 2):S12-21.
• Nasrallah HA. Atypical antipsychotic-induced metabolic side effects: insights from receptor-binding profiles. Mol Psychiatry. 2008;13(1):27-35.
• Reinhardt MM, Cohen CI. Late-Life Psychosis: Diagnosis and Treatment. Curr Psychiatry Rep. 2015;17:1.

Interprofessional care improves the outcomes of older adults with complex health problems

Elder Care Editors: Editor-in-Chief: Barry D Weiss, MD;  Deputy Editor: Mindy Fain, MD
 
 National Editorial Board: Theodore M Johnson II, MD, MPH, Emory University; Jenny Jordan, PT, DPT, Sacred Heart Hospital, Spokane, WA;  Jane Marks, RN, MS, FNGNA, Johns Hopkins University; Josette Rivera, MD, University of California San Francisco; Jean Yudin, CRNP, University of Pennsylvania
 
 Interprofessional Associate Editors: Carleigh High, PT, DPT; David Coon, PhD; Marilyn Gilbert, MS, CHES; Jeannie Lee, PharmD, BCPS; Marisa Menchola, PhD;  Francisco Moreno, MD; Linnea Nagel, PA-C, MPAS; Lisa O'Neill, DBH, MPH; Floribella Redondo; Laura Vitkus, MPH, CHES

Published by: The University of Arizona, PO Box 245027, Tucson, AZ 85724-5027  |  (520) 626-5800  | https://uofazcenteronaging.com

 This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1QHP28721, Arizona Geriatrics Workforce Enhancement Program.   This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.