Characteristics of very late-onset schizophrenia-like psychosis as prodromal dementia with Lewy bodies: a cross-sectional study

Characteristics associated with progression to probable dementia with Lewy bodies in a cohort with very late-onset psychosis

BACKGROUND

Very late-onset psychosis (VLOP) is associated with higher rates of dementia but the proportion who develop dementia with Lewy bodies (DLB) is unknown. We aimed to identify individuals with VLOP who develop dementia and DLB and characterize the risk factors for progression.

METHODS

Anonymized data were retrieved from electronic records for individuals with VLOP. Patients developing dementia after psychosis were identified, in addition to those with >2 core features of DLB at the time of dementia or DLB identified by a natural language processing application (NLP-DLB). Demographic factors, Health of the National Outcome Scale (HoNOS) and symptoms at index psychosis were explored as predictors of progression to dementia.

RESULTS

In 1425 patients with VLOP over 4.29 years (mean) follow up, 197 (13.8%) received a subsequent diagnosis of dementia. Of these, 24.4% (n = 48) had >2 core features of DLB and 6% (n = 12) had NLP-DLB. In cox proportional hazard models, older age and cognitive impairment at the time of psychosis were associated with increased risk of incident dementia. Visual hallucinations and 2+ core features of DLB at index psychosis were associated with increased risk of dementia with 2+ symptoms of DLB but not all-cause dementia. Two or more core features of DLB at index psychosis were associated with 81% specificity and 67% sensitivity for incident NLP-DLB.

CONCLUSIONS

In patients with VLOP who develop dementia, core features of DLB are common. Visual hallucinations or two core features of DLB in VLOP should prompt clinicians to consider DLB and support further investigation.

Clinical presentations and diagnostic application of proposed biomarkers in psychiatric-onset prodromal dementia with Lewy bodies

Research criteria for the diagnosis of prodromal dementia with Lewy bodies (DLB) include three clinical subtypes: mild cognitive impairment with Lewy bodies (MCI-LB), delirium-onset prodromal DLB, and psychiatric-onset prodromal DLB. Late-onset psychiatric manifestations are at a higher risk of developing dementia, but its relation to prodromal DLB remains unclear. In addition to the risk of severe antipsychotic hypersensitivity reactions, accurate discrimination from non-DLB cases is important due to the potential differences in management and prognosis. This article aims to review a rapidly evolving psychiatric topic and outline clinical pictures of psychiatric-onset prodromal DLB, including the proposed biomarker findings of MCI-LB: polysomnography-confirmed rapid eye movement sleep behaviour disorder, cardiac [123I]metaiodobenzylguanidine scintigraphy, and striatal dopamine transporter imaging. We first reviewed clinical pictures of patients with autopsy-confirmed DLB. Regarding clinical reports, we focused on the patients who predominantly presented with psychiatric manifestations and subsequently developed DLB. Thereafter, we reviewed clinical studies regarding the diagnostic applications of the proposed biomarkers to patients with late-onset psychiatric disorders. Clinical presentations were mainly late-onset depression and psychosis; however, other clinical manifestations were also reported. Psychotropic medications before a DLB diagnosis may cause extrapyramidal signs, and potentially influences the proposed biomarker findings. These risks complicate clinical manifestation interpretation during the management of psychiatric symptoms. Longitudinal follow-up studies with standardised evaluations until conversion to DLB are needed to investigate the temporal trajectories of core features and proposed biomarker findings. In patients with late-onset psychiatric disorders, identification of patients with psychiatric-onset prodromal DLB provides the opportunity to better understanding the distinct prognostic subgroup that is at great risk of incident dementia. Advances in the establishment of direct biomarkers for the detection of pathological α-synuclein may encourage reorganising the phenotypic variability of prodromal DLB.

Differentiating Prodromal Dementia with Lewy Bodies from Prodromal Alzheimer's Disease: A Pragmatic Review for Clinicians

This pragmatic review synthesises the current understanding of prodromal dementia with Lewy bodies (pDLB) and prodromal Alzheimer's disease (pAD), including clinical presentations, neuropsychological profiles, neuropsychiatric symptoms, biomarkers, and indications for disease management. The core clinical features of dementia with Lewy bodies (DLB)-parkinsonism, complex visual hallucinations, cognitive fluctuations, and REM sleep behaviour disorder are common prodromal symptoms. Supportive clinical features of pDLB include severe neuroleptic sensitivity, as well as autonomic and neuropsychiatric symptoms. The neuropsychological profile in mild cognitive impairment attributable to Lewy body pathology (MCI-LB) tends to include impairment in visuospatial skills and executive functioning, distinguishing it from MCI due to AD, which typically presents with impairment in memory. pDLB may present with cognitive impairment, psychiatric symptoms, and/or recurrent episodes of delirium, indicating that it is not necessarily synonymous with MCI-LB. Imaging, fluid and other biomarkers may play a crucial role in differentiating pDLB from pAD. The current MCI-LB criteria recognise low dopamine transporter uptake using positron emission tomography or single photon emission computed tomography (SPECT), loss of REM atonia on polysomnography, and sympathetic cardiac denervation using meta-iodobenzylguanidine SPECT as indicative biomarkers with slowing of dominant frequency on EEG among others as supportive biomarkers. This review also highlights the emergence of fluid and skin-based biomarkers. There is little research evidence for the treatment of pDLB, but pharmacological and non-pharmacological treatments for DLB may be discussed with patients. Non-pharmacological interventions such as diet, exercise, and cognitive stimulation may provide benefit, while evaluation and management of contributing factors like medications and sleep disturbances are vital. There is a need to expand research across diverse patient populations to address existing disparities in clinical trial participation. In conclusion, an early and accurate diagnosis of pDLB or pAD presents an opportunity for tailored interventions, improved healthcare outcomes, and enhanced quality of life for patients and care partners.

A Bird's-Eye Perspective: An Unusual Case of Very Late-Onset Schizophrenia-Like Psychosis With Visual Hallucinations Included in Its Manifestations Versus the Dementia Prodrome

Very late-onset schizophrenia-like psychosis (VLOSLP) is still a paradox; certain characteristics such as episodic progression of psychosis including delusions and hallucinations involving various modalities, as well as the absence of negative symptoms, are strongly predictive of VLOSLP. We describe an interesting case of a 61-year-old male who presented with a second episode of psychosis along with mild to moderate cognitive impairment like having difficulty in buttoning for over eight months at our tertiary care hospital. Previously, during the first episode, he was treated by a private practitioner; adequate doses for an adequate duration of two atypical antipsychotics were given; and up to 25% global improvement was reported by the caregiver. During the current episode, he experienced delusions, in which he had a conviction that a "WIFI" was capable of "thought-making" functions. During the past four months, his delusions exacerbated and were accompanied by hallucinations of other modalities, like visual and kinesthetic hallucinations, which profoundly impacted his daily life. He used to hear voices. While listening to the voices, he also experienced voices coming out of his mouth. All these were experienced by him in clear consciousness daily for a few hours. All plausible medical causes of late-onset psychosis, such as neuroinflammatory/immunological disorders, were ruled out. Neuroimaging revealed T2-weighted image (T2WI)/fluid-attenuated inversion recovery (FLAIR) hyperintensity in bilateral subcortical and periventricular deep white matter, suggestive of small vessel ischemic changes in the brain. The diagnosis of VLOSLP is completely rationalized by evidence-based medicine. Hence, the role of cerebrovascular risk factors, as well as age-related neurobiological processes, in the pathogenesis of VLOSLP is discussed. Future research ought to emphasize identifying a particular biomarker that would be highly predictive for accurately diagnosing VLOSLP and giving it an identity to separate it from various overlapping clinical conditions such as dementia with Lewy bodies (DLB) and other types of dementia with psychosis so that the patient can be given specific treatment.

Case report: Environmental adjustment for visual hallucinations in dementia with Lewy bodies based on photo assessment of the living environment

Background

Visual hallucinations (VH) are associated with visual prediction error in patients with dementia with Lewy bodies (DLB). Given this relationship, environmental adjustments have been suggested, but detailed contents for implementing such environmental adjustments and assessments are poorly documented. This case report preliminarily demonstrates methods for improving VH through our experience with two patients with DLB. We conducted familial interviews to assess the phenomenological features of VH and reviewed photographs of patients' homes to identify the environmental triggers of VH, known as photo assessment of the living environment (PA-LE).

Case description

Patient 1 was a 78-year-old woman with a Mini-Mental State Examination (MMSE) score of 11/30. She experienced seeing a stranger, children, and cats at home, which frightened her. VH frequently occurred in the living room and bedroom. The PA-LE showed that several environmental features, such as cushions on a sofa, the pattern on a carpet under a table, and clothing on hangers, were suggestive triggers of VH. Patient 2 was an 88-year-old woman with a MMSE score of 5/30. She had seen strangers, children, and animals at home, some of which were linked to a theft delusion. VH frequently occurred in the living room and bedroom. The PA-LE found that several environmental features, such as clothing on hangers and dolls, were suggestive of VH triggers. Non-pharmacological approaches were tailored to the patients' environmental and psychological states using interviews and PA-LE. This included removing environmental triggers, reducing negative mood, and providing coping strategies for VH. This improved their VH and their caregivers' knowledge of VH.

Conclusion

Phenomenological assessments using photographs of the patient's home could identify the environmental triggers associated with VH in patients with DLB and assist in environmental adjustments.

Care for Social Isolation and Loneliness in a Case With Late-Onset Delusional Disorder

Late-onset psychosis refers to the development of psychotic symptoms after the age of 40 and can encompass various conditions like schizophrenia, mood disorders with psychotic features, and delusional disorder. Non-pharmacological interventions are critically important in older adults with psychosis, especially considering the lack of evidence for the efficacy of antipsychotics and the high risk of side effects. Social isolation is recognized as one of the risks of late-onset psychosis, and interventions to eliminate this risk are becoming increasingly important in Japan, where social isolation among older people is widespread as society ages. We present a case of late-onset delusional disorder in which multidimensional interventions for social isolation and loneliness, which have significant impacts on symptoms, were effective in achieving persistent remission. The case involved a woman in her mid-70s who began to complain of paranoia that taking a painkiller recommended by her husband caused persistent pain. Her husband's hospitalization and the deterioration of her relationship with her children resulted in her becoming socially isolated, which intensified her delusions and led to aggressive behavior and depression. Although antipsychotic medications had a limited effect, remission was achieved through supportive psychotherapy, cognitive therapy, family education, participation in group occupational therapy, and the introduction of daycare services, which were implemented to reduce loneliness and social isolation. Specifically, supportive psychotherapy and family education for her loneliness, awareness of another possible cause of pain that she developed through Socratic questioning, and environmental adjustments played important roles in preparing her to accept cognitive therapy, achieve delusional remission, and maintain her state of remission, respectively. The interventions implemented in this case provide insights for addressing social isolation and loneliness in late-onset psychosis.

Characteristics of very late-onset schizophrenia-like psychosis classified with the biomarkers for Alzheimer's disease: a retrospective cross-sectional study

OBJECTIVES

We aimed to investigate the association between very late-onset schizophrenia-like psychosis (VLOSLP), a schizophrenia spectrum disorder with an onset of ≥60 years, and Alzheimer's disease (AD) using biomarkers.

DESIGN

Retrospective cross-sectional study.

SETTING

Neuropsychology clinic of Osaka University Hospital in Japan.

PARTICIPANTS

Thirty-three participants were classified into three groups: eight AD biomarker-negative VLOSLP (VLOSLP-AD), nine AD biomarker-positive VLOSLP (VLOSLP+AD), and sixteen amnestic mild cognitive impairment due to AD without psychosis (aMCI-P+AD) participants.

MEASUREMENTS

Phosphorylated tau levels in the cerebrospinal fluid and 18F-Florbetapir positron emission tomography results were used as AD biomarkers. Several scales (e.g. the Mini-Mental State Examination (MMSE), Wechsler Memory Scale-Revised (WMS-R) Logical Memory (LM) I and II, and Neuropsychiatric Inventory (NPI)-plus) were conducted to assess clinical characteristics.

RESULTS

Those in both VLOSLP-AD and +AD groups scored higher than those in aMCI-P+AD in WMS-R LM I. On the other hand, VLOSLP+AD participants scored in between the other two groups in the WMS-R LM II, with only VLOSLP-AD participants scoring significantly higher than aMCI-P+AD participants. There were no significant differences in sex distribution and MMSE scores among the three groups or in the subtype of psychotic symptoms between VLOSLP-AD and +AD participants. Four VLOSLP-AD and five VLOSLP+AD participants harbored partition delusions. Delusion of theft was shown in two VLOSLP-AD patients and five VLOSLP+AD patients.

CONCLUSION

Some VLOSLP patients had AD pathology. Clinical characteristics were different between AD biomarker-positive and AD biomarker-negative VLOSLP, which may be helpful for detecting AD pathology in VLOSLP patients.

Psychosis in Neurodegenerative Dementias: A Systematic Comparative Review

Background

Psychosis, characterized by delusions and/or hallucinations, is frequently observed during the progression of Alzheimer's disease (AD) and other neurodegenerative dementias (ND) (i.e., dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD)) and cause diagnostic and management difficulties.

Objective

This review aims at presenting a concise and up-to-date overview of psychotic symptoms that occur in patients with ND with a comparative approach.

Methods

A systematic review was conducted following the PRISMA guidelines. 98 original studies investigating psychosis phenotypes in neurodegenerative dementias were identified (40 cohort studies, 57 case reports).

Results

Psychosis is a frequently observed phenomenon during the course of ND, with reported prevalence ranging from 22.5% to 54.1% in AD, 55.9% to 73.9% in DLB, and 18% to 42% in FTD. Throughout all stages of these diseases, noticeable patterns emerge depending on their underlying causes. Misidentification delusions (16.6-78.3%) and visual hallucinations (50-69.6%) are frequently observed in DLB, while paranoid ideas and somatic preoccupations seem to be particularly common in AD and FTD, (respectively 9.1-60.3% and 3.10-41.5%). Limited data were found regarding psychosis in the early stages of these disorders.

Conclusions

Literature data suggest that different ND are associated with noticeable variations in psychotic phenotypes, reflecting disease-specific tendencies. Further studies focusing on the early stages of these disorders are necessary to enhance our understanding of early psychotic manifestations associated with ND and help in differential diagnosis issues.

The clinical phenotype of psychiatric-onset prodromal dementia with Lewy bodies: a scoping review

BACKGROUND

Recent consensus research criteria have identified a 'psychiatric onset' form of prodromal dementia with Lewy bodies (DLB) characterised by prominent late-onset psychiatric symptoms. Although recognised as important to raise the index of diagnostic suspicion, evidence regarding this cohort was deemed too limited to impose formal criteria. We reviewed the published literature on psychiatric-onset DLB to identify key clinical characteristics and evidence gaps to progress our understanding of this entity.

METHODS

Medline, PubMed and Embase were searched for relevant articles containing longitudinal follow-up of patients initially presenting with a psychiatric illness who subsequently developed DLB according to the diagnostic criteria available at the time.

RESULTS

Two cohort studies (18 and 21 patients) along with 12 case series (13 cases) were identified totalling 52 patients (63% female). Initial psychiatric presentation occurred at a mean of 63 years (range 53-88), with depression being the most frequently reported psychiatric presentation (88%). Psychotic presentations were less common on presentation (11%) but became more prevalent throughout the prodromal period before the diagnosis of DLB (83%). Relapses of the psychiatric disease were common occurring in 94% (32/34) of patients. Parkinsonism, cognitive fluctuations, visual hallucinations, and REM sleep behaviour disorder were uncommonly reported at initial presentation (3.8%).

CONCLUSIONS

Psychiatric-onset DLB is characterized by a female predominant relapsing-remitting psychiatric illness presenting with affective symptoms but later developing psychotic features prior to the onset of DLB. Additional prospective studies including other neurodegenerative cohorts with harmonised assessments are required to inform definitive diagnostic criteria for this condition.

Under-Diagnosis of Dementia with Lewy Bodies in Individuals Racialized as Black: Hypotheses Regarding Potential Contributors

Dementia with Lewy bodies (DLB) is one of the most common degenerative dementias after Alzheimer's disease (AD) dementia. DLB is under-diagnosed across populations but may be particularly missed in older Black adults. The object of this review was to examine key features of DLB and potential associations with race in order to hypothesize why DLB may be under-diagnosed in Black adults in the U.S. In terms of dementia, symptoms associated with high rates of co-pathology (e.g., AD, vascular disease) in older Black adults may obscure the clinical picture that might suggest Lewy body pathology. Research also suggests that clinicians may be predisposed to give AD dementia diagnoses to Black adults, potentially missing contributions of Lewy body pathology. Hallucinations in Black adults may be misattributed to AD or primary psychiatric disease rather than Lewy body pathology. Research on the prevalence of REM sleep behavior in diverse populations is lacking, but REM sleep behavior disorder could be under-diagnosed in Black adults due to sleep patterns or reporting by caregivers who are not bed partners. Recognition of parkinsonism could be reduced in Black adults due to clinician biases, cultural effects on self-report, and potentially underlying differences in the frequency of parkinsonism. These considerations are superimposed on structural and systemic contributions to health (e.g., socioeconomic status, education, structural racism) and individual-level social exposures (e.g., social interactions, discrimination). Improving DLB recognition in Black adults will require research to investigate reasons for diagnostic disparities and education to increase identification of core symptoms in this population.

Psychiatric onset of prodromal dementia with Lewy bodies: Current insights into neuroimaging tools

PURPOSE

Our article is dedicated to describing the state-of-the-art in imaging techniques for assessing prodromal dementia with Lewy bodies (pro-DLB) with a psychiatric-onset.

MATERIALS AND METHODS

Imaging biomarker techniques are discussed.

RESULTS

(123)-I-2-ß-carbomethoxy-3ß-(4-iodophenyl)-N-(3-fluoropropyl) nortropane single photon emission computed tomography (123I-FP-CIT SPECT) seems to be a promising method as it reveals abnormalities in pro-DLB with a psychiatric-onset. New potential biomarkers can be revealed via novel techniques, such as manual segmentation in magnetic resonance imaging (MRI), which helps detect atrophy of the substantia innominata in pro-DLB with a psychiatric-onset as opposed to an onset with mild cognitive impairment (MCI). FDG-PET can also help us distinguish patients with mixed pro-DLB from those pro-DLB patients with a psychiatric-onset or MCI-onset. Changes in large-scale networks in the posterior standard mode and in attentional networks could be early signs in resting-state functional MRI to characterise pro-DLB.

CONCLUSIONS

In conclusion, there is a wide range of techniques that need to be explored in large-scale studies and are of promising value in understanding pro-DLB with a psychiatric-onset.

Case report: Delusional infestation in dementia with Lewy bodies

BACKGROUND

Delusional infestation is characterized by delusions of being infested with parasites, vermin, or small insects and is frequently accompanied by tactile and visual hallucinations. Herein, we report two cases of dementia with Lewy bodies (DLB) with delusional infestation.

CASE PRESENTATION

Case 1 was an 83-year-old man. At the age of 75, he began to show symptoms of rapid eye movement sleep behavior disorder. At the age of 83, he began to complain of visual hallucinations of people and delusional infestation with tactile and visual hallucinations of insects, resulting in the use of insecticides for non-existent insects. He also complained of mild amnesia and was admitted to our psychiatric ward for evaluation and treatment. After admission, the delusional infestation disappeared without any new medication. Based on our examinations, he was diagnosed with probable DLB with delusional infestation. He was treated with 5 mg/day of donepezil hydrochloride; his visual and tactile hallucinations disappeared, and the delusional infestation had not recurred at the 1-year follow-up. Case 2 was a 69-year-old woman. At the age of 60, she underwent clipping for subarachnoid hemorrhage (SAH). At the age of 65, she began to have visual hallucinations of people. At the age of 67, she began to complain of visual illusions in which she mistook lint for insects. At the age of 69, she developed delusional infestation and mild amnesia. She took various actions to get rid of these non-existent insects, including insecticide use, consulting an exterminator, and visiting several dermatologists. She eventually burnt her leg in an attempt to kill the non-existent insects. Based on our examinations, she was diagnosed with prodromal DLB in addition to SAH sequelae. We determined that her delusional infestation was caused by DLB rather than SAH sequelae based on the course of her symptoms. She was treated with a combination of 3 mg/day of donepezil hydrochloride and 12.5 mg/day of quetiapine. Thereafter, the delusional infestation partially improved, and she took no further action against non-existent insects.

CONCLUSION

Delusional infestation may be caused by DLB. Acetylcholinesterase inhibitors (AChEI) may be effective for delusional infestation in DLB, although antipsychotics may also be needed in severe cases.