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Psychosis and dementia: risk factor, prodrome, or cause?

Published online by Cambridge University Press:  31 May 2017

Corinne E. Fischer
Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada Institute of Medical Sciences, University of Toronto, Toronto, Ontario, Canada Faculty of Medicine, Department of Psychiatry, University of Toronto, Canada
Luis Agüera-Ortiz
Department of Psychiatry & Instituto de Investigación Sanitaria (imas12), Hospital Universitario 12 de Octubre, Madrid, Spain Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM
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Progression of dementia is often associated with the emergence of neuropsychiatric symptoms (NPS), though there is recent evidence that NPS may occur in prodromal dementia (PrD) and impact clinical course. Mood and anxiety symptoms are the NPS that tend to occur most frequently in PrD and thus have been most extensively studied. Comparatively, there has been little focus on psychotic symptoms in PrD.


The authors review the existing literature on psychosis in PrD, including the functional psychosis of early and late onset, with a focus on epidemiology, phenomenology, and clinical course and treatment considerations.


Patients with psychotic disorders at baseline such as schizophrenia may be more at risk for developing dementia over time, although this is not completely clear. Psychotic symptoms are likely more common in PrD than previously understood based on factor analysis studies, although they are much more common in established dementia. Variability in findings may reflect the heterogeneous nature of PrD studies to date and the lack of inclusion of patients with late onset psychosis in most clinical studies. The presence of psychosis in patients with PrD may be associated with a worse prognosis in terms of mortality and conversion to dementia.


Research to date suggests that psychosis in PrD may be more common than previously thought and impact clinical course negatively. Future studies incorporating patients with late onset psychotic disorders, and focusing on the impact of early recognition and treatment, are required to more fully understand the role of psychosis in PrD.

Review Article
Copyright © International Psychogeriatric Association 2017 

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Alzheimer Society of Canada (2010). Rising tide: the impact of dementia on Canadian society., last accessed 20 May 2017.Google Scholar
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th edn. Arlington, VA: American Psychiatric Publishing.Google Scholar
Apostolova, L. G. and Cummings, J. L. (2008). Neuropsychiatric manifestations in mild cognitive impairment: a systematic review of the literature. Dementia and Geriatric Cognitive Disorders, 25, 115126.CrossRefGoogle ScholarPubMed
Apostolova, L. G. et al. (2014). Risk factors for behavioral abnormalities in mild cognitive impairment and mild Alzheimer's disease. Dementia and Geriatric Cognitive Disorders, 37, 315326.CrossRefGoogle ScholarPubMed
Brodaty, H., Sachdev, P., Koschera, A., Monk, D. and Cullen, B. (2003). Long-term outcome of late-onset echizophrenia: 5 years follow-up study. British Journal of Psychiatry, 183, 213219.CrossRefGoogle Scholar
Castle, D. J. and Murray, R. M. (1993). The epidemiology of late-onset schizophrenia. Schizophr Bull, 19, 691700.CrossRefGoogle ScholarPubMed
Chung, J. K. et al. (2016). Beta-Amyloid burden is not associated with cognitive impairment in schizophrenia: a systematic review. American Journal of Geriatric Psychiatry, 24, 923939.CrossRefGoogle Scholar
Copeland, M. P. et al. (2003). Psychiatric symptomatology and prodromal Alzheimer's disease. Alzheimer Disease & Associated Disorders, 17, 18.CrossRefGoogle ScholarPubMed
Ellison, J. M., Harper, D. G., Berlow, Y. and Zeranski, L. (2008). Beyond the “C” in MCI: noncognitive symptoms in amnestic and non-amnestic mild cognitive impairment. CNS Spectrums, 13, 6672.CrossRefGoogle ScholarPubMed
Emanuel, J. E. et al. (2011). Trajectory of cognitive decline as a predictor of psychosis in early Alzheimer disease in the cardiovascular health study. American Journal of Geriatric Psychiatry, 19, 160168.CrossRefGoogle ScholarPubMed
Ferman, T. J. et al. (2013). Nonamnestic mild cognitive impairment progresses to dementia with Lewy bodies. Neurology, 81, 20322038.CrossRefGoogle ScholarPubMed
Fischer, C. E. and Sweet, R. A. (2016). Psychosis in Alzheimer's disease: a review of recent research findings. Current Behavioural Neurosciences, In press.CrossRefGoogle Scholar
Hanssen, M. et al. (2015). Comparative study of clinical and neuropsychological characteristics between early-, late and very-late-onset schizophrenia-spectrum disorders. American Journal of Geriatric Psychiatry, 23, 852862.CrossRefGoogle ScholarPubMed
Howard, R., Rabins, P. V., Seeman, M. V. and Jeste, D. V. (2000). Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. The international late-onset schizophrenia group. American Journal of Psychiatry, 157, 172178.CrossRefGoogle ScholarPubMed
Ismail, Z. et al. (2016). Neuropsychiatric symptoms as early manifestations of emergent dementia: provisional diagnostic criteria for mild behavioral impairment. Alzheimers Dement, 12, 195202.CrossRefGoogle ScholarPubMed
Ismail, Z. et al. (2017). The mild behavioral impairment checklist (MBI-C): a rating scale for neuropsychiatric symptoms in pre-dementia populations. Journal of Alzheimers Disease, 56, 929938.CrossRefGoogle ScholarPubMed
Jicha, G. A. et al. (2010). Prodromal clinical manifestations of neuropathologically confirmed Lewy body disease. Neurobiology of Aging, 31, 18051813.CrossRefGoogle ScholarPubMed
Jost, B. C. and Grossberg, G. T. (1996). The evolution of psychiatric symptoms in Alzheimer's disease: a natural history study. Journal of the American Geriatrics Society, 44, 10781081.CrossRefGoogle ScholarPubMed
Kaymaz, N. et al. (2012). Do subthreshold psychotic experiences predict clinical outcomes in unselected non-help-seeking population-based samples? A systematic review and meta-analysis, enriched with new results. Psychological Medicine, 42, 22392253.CrossRefGoogle ScholarPubMed
Kirkpatrick, B., Messias, E., Harvey, P. D., Fernandez-Egea, E. and Bowie, C. R. (2008). Is schizophrenia a syndrome of accelerated aging? Schizophr Bull, 34, 10241032.CrossRefGoogle ScholarPubMed
Kohler, S. et al. (2013). Cognitive decline and dementia risk in older adults with psychotic symptoms: a prospective cohort study. American Journal of Geriatric Psychiatry, 21, 119128.CrossRefGoogle ScholarPubMed
Korner, A., Lopez, A. G., Lauritzen, L., Andersen, P. K. and Kessing, L. V. (2009). Acute and transient psychosis in old age and the subsequent risk of dementia: a nationwide register-based study. Geriatrics & Gerontology International, 9, 6268.CrossRefGoogle ScholarPubMed
Kraepelin, E. (1904). Psychiatrie. Ein Lehrbuch für Studierende und Ärtze. Leipzig: Barth.Google Scholar
Lanctot, K. L. et al. (2003). Efficacy and safety of cholinesterase inhibitors in Alzheimer's disease: a meta-analysis. Canadian Medical Association Journal, 169, 557564.Google ScholarPubMed
Leroi, I., Pantula, H., Mcdonald, K. and Harbishettar, V. (2012). Neuropsychiatric symptoms in Parkinson's disease with mild cognitive impairment and dementia. Parkinsons Disease, 2012, 308097.Google ScholarPubMed
Loewenstein, D. A., Czaja, S. J., Bowie, C. R. and Harvey, P. D. (2012). Age-associated differences in cognitive performance in older patients with schizophrenia: a comparison with healthy older adults. American Journal of Geriatric Psychiatry, 20, 2940.CrossRefGoogle ScholarPubMed
Lyketsos, C. G., Lopez, O., Jones, B., Fitzpatrick, A. L., Breitner, J. and Dekosky, S. (2002). Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study. JAMA, 288, 14751483.CrossRefGoogle ScholarPubMed
Modrego, P. J. and Ferrandez, J. (2004). Depression in patients with mild cognitive impairment increases the risk of developing dementia of Alzheimer type: a prospective cohort study. Archives of Neurology, 61, 12901293.CrossRefGoogle ScholarPubMed
Muangpaisan, W., Intalapaporn, S. and Assantachai, P. (2008). Neuropsychiatric symptoms in the community-based patients with mild cognitive impairment and the influence of demographic factors. International Journal of Geriatric Psychiatry, 23, 699703.CrossRefGoogle ScholarPubMed
Nuechterlein, K. H., Barch, D. M., Gold, J. M., Goldberg, T. E., Green, M. F. and Heaton, R. K. (2004). Identification of separable cognitive factors in schizophrenia. Schizophrenia Research, 72, 2939.CrossRefGoogle Scholar
Nuevo, R., Van Os, J., Arango, C., Chatterji, S. and Ayuso-Mateos, J. L. (2013). Evidence for the early clinical relevance of hallucinatory-delusional states in the general population. Acta Psychiatrica Scandinavica, 127, 482493.CrossRefGoogle ScholarPubMed
Palmer, K., Berger, A. K., Monastero, R., Winblad, B., Backman, L. and Fratiglioni, L. (2007). Predictors of progression from mild cognitive impairment to Alzheimer disease. Neurology, 68, 15961602.CrossRefGoogle ScholarPubMed
Peters, M. E. et al. (2013). Neuropsychiatric symptoms as risk factors for progression from CIND to dementia: the Cache County Study. American Journal of Geriatric Psychiatry, 21, 11161124.CrossRefGoogle ScholarPubMed
Peters, M. E. et al. (2015). Neuropsychiatric symptoms as predictors of progression to severe Alzheimer's dementia and death: the cache county dementia progression study. American Journal of Psychiatry, 172, 460465.CrossRefGoogle ScholarPubMed
Petersen, R. C. (2011). Clinical practice. Mild cognitive impairment. New England Journal of Medicine, 364, 22272234.CrossRefGoogle ScholarPubMed
Piccininni, M., Di Carlo, A., Baldereschi, M., Zaccara, G. and Inzitari, D. (2005). Behavioral and psychological symptoms in Alzheimer's disease: frequency and relationship with duration and severity of the disease. Dementia and Geriatric Cognitive Disorders, 19, 276281.CrossRefGoogle ScholarPubMed
Rajji, T. K. et al. (2013). Cognitive performance of individuals with schizophrenia across seven decades: a study using the MATRICS consensus cognitive battery. American Journal of Geriatric Psychiatry, 21, 108118.CrossRefGoogle ScholarPubMed
Rapp, M. A. et al. (2010). Cortical neuritic plaques and hippocampal neurofibrillary tangles are related to dementia severity in elderly schizophrenia patients. Schizophrenia Research, 116, 9096.CrossRefGoogle ScholarPubMed
Reeves, R. R. and Brister, J. C. (2008). Psychosis in late life: emerging issues. Journal of Psychosocial Nursing and Mental Health Services, 46, 4552.CrossRefGoogle ScholarPubMed
Ribe, A. R. et al. (2015). Long-term risk of dementia in persons With Schizophrenia: a danish population-based cohort study. JAMA Psychiatry, 72, 10951101.CrossRefGoogle ScholarPubMed
Rozzini, L. et al. (2008). Neuropsychiatric symptoms in amnestic and nonamnestic mild cognitive impairment. Dementia and Geriatric Cognitive Disorders, 25, 3236.CrossRefGoogle ScholarPubMed
Scarmeas, N. et al. (2005). Delusions and hallucinations are associated with worse outcome in Alzheimer disease. Archives of Neurology, 62, 16011608.CrossRefGoogle ScholarPubMed
Schneider, L. S., Dagerman, K. S. and Insel, P. (2005). Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA, 294, 19341943.CrossRefGoogle ScholarPubMed
Serra, L. et al. (2010). Are the behavioral symptoms of Alzheimer's disease directly associated with neurodegeneration? Journal of Alzheimers Disease, 21, 627639.CrossRefGoogle ScholarPubMed
Shah, J. N., Qureshi, S. U., Jawaid, A. and Schulz, P. E. (2012). Is there evidence for late cognitive decline in chronic schizophrenia? Psychiatric Quarterly, 83, 127144.CrossRefGoogle ScholarPubMed
Tariot, P. N. et al. (2006). Quetiapine treatment of psychosis associated with dementia: a double-blind, randomized, placebo-controlled clinical trial. American Journal of Geriatr Psychiatry, 14, 767776.CrossRefGoogle ScholarPubMed
Van Der Mussele, S. et al. (2013). Prevalence and associated behavioral symptoms of depression in mild cognitive impairment and dementia due to Alzheimer's disease. International Journal of Geriatric Psychiatry, 28, 947958.CrossRefGoogle ScholarPubMed
Van Der Mussele, S. et al. (2014). Behavioral syndromes in mild cognitive impairment and Alzheimer's disease. Journal of Alzheimers Disease, 38, 319329.CrossRefGoogle ScholarPubMed
Van Os, J. and Reininghaus, U. (2016). Psychosis as a transdiagnostic and extended phenotype in the general population. World Psychiatry, 15, 118124.CrossRefGoogle ScholarPubMed
Van Os, J., Howard, R., Takei, N. and Murray, R. (1995). Increasing age is a risk factor for psychosis in the elderly. Social and Psychiatry and Psychiatric Epidemiology, 30, 161164.CrossRefGoogle ScholarPubMed
Vicini Chilovi, B., Conti, M., Zanetti, M., Mazzu, I., Rozzini, L. and Padovani, A. (2009). Differential impact of apathy and depression in the development of dementia in mild cognitive impairment patients. Dementia and Geriatric Cognitive Disorders, 27, 390398.CrossRefGoogle ScholarPubMed
Wadsworth, L. P. et al. (2012). Neuropsychiatric symptoms and global functional impairment along the Alzheimer's continuum. Dementia and Geriatric Cognitive Disorders, 34, 96111.CrossRefGoogle ScholarPubMed
Weamer, E. A. et al. (2009). The relationship of excess cognitive impairment in MCI and early Alzheimer's disease to the subsequent emergence of psychosis. International Psychogeriatrics, 21, 7885.CrossRefGoogle Scholar
Zilkens, R. R., Bruce, D. G., Duke, J., Spilsbury, K. and Semmens, J. B. (2014). Severe psychiatric disorders in mid-life and risk of dementia in late-life (age 65–84 years): a population based case-control study. Current Alzheimer Research, 11, 681693.CrossRefGoogle ScholarPubMed

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