Neuropathology of psychotic symptoms in Alzheimer's disease

Management of Dementia-Related Psychosis, Agitation and Aggression: A Review of the Pharmacology and Clinical Effects of Potential Drug Candidates

Along with cognitive decline, 90% of patients with dementia experience behavioral and psychological symptoms of dementia, such as psychosis, aggression, agitation, and depression. Atypical antipsychotics are commonly prescribed off-label to manage certain symptoms, despite warnings from the regulatory agencies regarding the increased risk of mortality associated with their use in elderly patients. Moreover, these compounds display a limited clinical efficacy, mostly owing to the fact that they were developed to treat schizophrenia, a disease characterized by neurobiological deficits. Thus, to improve clinical efficacy, it has been suggested that patients with dementia should be treated with exclusively designed and developed drugs that interact with pharmacologically relevant targets. Within this context, numerous studies have suggested druggable targets that might achieve therapeutically acceptable pharmacological profiles. Based on this, several different drug candidates have been proposed that are being investigated in clinical trials for behavioral and psychological symptoms of dementia. We highlight the recent advances toward the development of therapeutic agents for dementia-related psychosis and agitation/aggression and discuss the relationship between the relevant biological targets and their etiology. In addition, we review the compounds that are in the early stage of development (discovery or preclinical phase) and those that are currently being investigated in clinical trials for dementia-related psychosis and agitation/aggression. We also discuss the mechanism of action of these compounds and their pharmacological utility in patients with dementia.

Behavioral disturbances in dementia

Psychological symptoms and behavioral abnormalities are common and prominent characteristics of dementia. They include symptoms such as depression, anxiety psychosis, agitation, aggression, disinhibition, and sleep disturbances. Approximately 30% to 90% of patients with dementia suffer from such behavioral disorders. There are complex interactions between cognitive deficits, psychological symptoms, and behavioral abnormalities. A large number of standardized, reliable, and well-validated instruments for assessing the behavioral and psychological symptoms of dementia have been developed in order to evaluate the efficacy of treatment. Neurodegenerative processes in various brain areas, particularly in the frontotemporal cortex and limbic regions, leading to cholinergic, serotonergic, and noradrenergic neurotransmitter dysfunctions constitute the biological matrix of behavioral symptoms, whereas psychological factors and personality traits play a modifying role. A large number of pharmacological, psychoeducational, psychotherapeutic, and social strategies have been developed to improve the quality of life of patients and their caregivers.

[Psychosis in elderly post-traumatic stress disorder patients]

BACKGROUND

Late-onset post-traumatic stress disorder (PTSD) patients with traumatic experiences from World War II often present psychotic features.

METHODS

Twelve psychotic elderly PTSD patients were compared with 22 nonpsychotic elderly PTSD patients for age, marital status, age of traumatization, age of onset of psychiatric symptoms, and psychiatric comorbidities. The contents of delusions and hallucinations were registered as well as trauma details.

RESULTS

The psychotic PTSD patients were significantly older (80 years vs 74), later traumatized (20 years vs 14), more frequently demented (75% vs 27%), and more frequently widowed (83% vs 50%). The contents of their psychotic features often were related to traumatic experiences in early life.

CONCLUSIONS

Psychoses of traumatized elderly patients should be registered regarding psychotic content to discover a possible relation between traumatic experiences and psychosis. The International Classification of Diseases 11th Edition should include the subtype "PTSD with simultaneous psychotic features."