Dementia: Update for the Practitioner

If a patient does not have a symptom, how likely is it to appear? And once it occurs, how persistent is it? Data from a multicenter study at Columbia University, Johns Hopkins University, and Massachusetts General Hospital in Boston are representative of what we know about the psychopathology in Alzheimer's disease, how common the symptoms are, and what happens over time.

This study systematically tracked over time 236 patients who had mild Alzheimer's disease. I should mention that only in the last few years, the latter part of this study, have cholinesterase inhibitors or other treatments been available, so this study plots the natural course of the illness.

The majority of patients had one or more psychiatric symptoms at baseline. This was assessed on a scale that I developed with my collaborators that is easy to administer reliably in a very large number of people. Less than 10 percent of patients remained free of all symptoms of psychopathology during the course of illness, so we have to say that symptoms of psychopathology—agitation, aggression, depression, anxiety, insomnia—are the norm during the course of Alzheimer's disease. It is not only a disorder of memory or cognition.

Paranoid delusions occurred in about 10 to 20 percent of patients and did not increase much with the severity of illness. In fact, if you follow patients out six to seven years, the prevalence of delusions actually drops. We do not know if the true prevalence is dropping or if the patient's dementia has become so severe that he or she cannot report delusions if they occur.


	Paranoid Delusions


	Paranoid delusions occur in about 10 to 20 percent of patients with Alzheimer's disease, and do not increase much with the severity of the illness. Courtesy of Dr. Davangere P. Devanand. Source of data: D. P. Devanand et al., "The Course of Psychopathologic Features in Mild to Moderate Alzheimer's Disease," Archives of General Psychiatry 54, no.3 (1997): 257–63.


	Misidentification Delusions


	Misidentification increases over time in patients with Alzheimer's disease. Courtesy of Dr. Davangere P. Devanand. Source of data: D. P. Devanand et al., "The Course of Psychopathologic Features in Mild to Moderate Alzheimer's Disease," Archives of General Psychiatry 54, no. 3 (1997): 257–63.


	Hallucinations


	The proportion of Alzheimer's patients with psychosis, paranoid delusions, and hallucinations does not increase over time, remaining at about 10 to 20 percent. Courtesy of Dr. Davangere P. Devanand. Source of data: D. P. Devanand et al., "The Course of Psychopathologic Features in Mild to Moderate Alzheimer's Disease," Archives of General Psychiatry 54, no. 3 (1997): 257–63.


	Agitation or Wandering


	Psychomotor agitation is common among Alzheimer's patients; one-third to half of patients develop it to some degree. Courtesy of Dr. Davangere P. Devanand. Source of data: D. P. Devanand et al., "The Course of Psychopathologic Features in Mild to Moderate Alzheimer's Disease," Archives of General Psychiatry 54, no. 3 (1997;): 257–63.


	Physical Aggression


	Physical aggression towards people is quite rare early in the course of Alzheimer's disease. Courtesy of Dr. Davangere P. Devanand. Source of data: D. P. Devanand et al., "The Course of Psychopathologic Features in Mild to Moderate Alzheimer's Disease," Archives of General Psychiatry 54, no. 3 (1997): 257–63.


	Depressed Mood


	Depressed mood is seen in about 15 to 20 percent of Alzheimer's patients, and for most the symptoms are mild. Courtesy of Dr. Davangere P. Devanand. Source of data: D. P. Devanand et al., "The Course of Psychopathologic Features in Mild to Moderate Alzheimer's Disease," Archives of General Psychiatry 54, no. 3 (1997): 257–63.

Misidentification, as you might expect, increases over time. Later on in the course of illness patients may be unable to recognize family members. This is probably more a disorder of cognition than a delusion per se.

In conditions like schizophrenia and other primary psychotic disorders, auditory hallucinations are more common than other sensory modalities. In Alzheimer's disease, visual hallucinations are as common as auditory hallucinations. One of the striking features about these hallucinations is that they are usually not very well formed. The patient will see a coat in a closet and worry that there is someone there, or will hear a sound and think that someone is in the house.

It is uncommon for Alzheimer's patients to have a clearly defined auditory hallucination in which they hear voices talking to each other and that they can relate to you an exact conversation the way a patient with schizophrenia can. More often, they hear or see something at times but not at others, and when asked about this the patient says, "No, that did not happen." These hallucinations are not very common during the course of illness, appearing in about 5 to 10 percent of patients. These can be disturbing, but usually occur in the context of agitation rather than in isolation. Often treatments will address both the agitation and the psychotic features. Interestingly, the proportion of patients with psychosis, paranoid delusions, and hallucinations does not increase over time, remaining at about 10 to 20 percent.

Psychomotor agitation, defined broadly to include people who try to wander away or are restless and agitated, is really quite common; one-third to half of patients with Alzheimer's develop it to some degree. Most patients have this symptom to a mild degree. Though not severe, this is the most striking behavioral change and the symptom that most commonly presents as something requiring treatment. Several studies suggest that further in the course of illness, this becomes even more frequent. More than 50 percent of patients with Alzheimer's disease in nursing homes have some degree of agitation.

Physical aggression towards people is quite rare early in the course of illness, while in nursing homes aggression occurs in 20 to 30 percent of patients. I should mention that some of these behavioral symptoms, like agitation and aggression, are driven in part by the interaction of the patient with the environment. Agitation and aggression can fluctuate depending on the way in which family members or nursing home staff deal with the patient, especially for those with milder forms of agitation or aggression. In more severe forms it seems to be endogenously driven by brain changes.

Depressed mood is seen in about 15 to 20 percent of patients, and for most the symptoms are mild. It is uncommon to see severe depression or psychotic depression in a patient with Alzheimer's disease.

Finally, intervention is more likely as a patient progresses from living alone or with family members, to requiring home care, to needing nursing-home care, and the patient is more likely to develop symptoms and need psychotropic agents.


	Caregivers: Health Effects Elevated blood pressure Altered plasma lipid levels Poor self-care Lack of exercise and sleep High use of psychotropic drugs

	Health effects also appear in Alzheimer's patients' caregivers. Courtesy of Dr. Davangere P. Devanand


	Impact on Caregivers

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