Hallucinations and Delusions Related to Dementia Impact Patient Outcomes, Caregiver Burden

Dementia is common in older adults, affecting approximately 7.9 million people in the United States, of whom 5.5 million have Alzheimer’s disease (AD). As the population ages, the number of people with dementia is expected to grow and projected to affect 13.8 million people by 2050.

During an Industry Symposium at the Neuroscience Education Institute Max! Virtual Meeting, Gustavo Alva, MD, assistant professor in the Department of Psychiatry and Neuroscience at the University of California-Riverside, and Kristy Aro, a caregiver for her mother who has AD dementia, discussed hallucinations and delusions associated with dementia-related psychosis.

Ms. Aro recalled how she realized something was wrong with her mother when she started forgetting to return her calls, as they would always talk multiple times per day. Her mother was referred to a neurologist who diagnosed her with AD dementia. Currently, Ms. Aro supports her father in caring for her mother.

Hallucinations are perception-like experiences that occur without an external stimulus and are sensory in nature. Delusions are a false, fixed belief despite evidence to the contrary. These are frequent, persistent problems that may recur over time. Dementia-related hallucinations and delusions may also be associated with aggression.

Ms. Aro described how her mother thought her father was an imposter and reported seeing her parents who had passed away — indicating the first symptoms of hallucinations and delusions.

Hallucinations and delusions are associated with behavioral, psychological, and cognitive problems in people with dementia, including insomnia, confusion, agitation, personality change, and self-care problems. “That really creates quite a burden,” said Dr. Alva.

Neuropsychiatric symptoms, including delusions, may also increase the likelihood of nursing home placement for older patients with dementia. “If a caregiver is no longer able to care for the needs of their loved one, a higher level of care is going to be required,” he said. A greater severity of dementia and even death are possible in patients with hallucinations and delusions.

Approximately 70% of older adults with dementia receive support from family caregivers, and caregivers face a high burden, which could lead to institutionalization of the patient with dementia. Dr. Alva noted that even professional caregivers of these patients can report burnout and exhaustion due to patients’ behavioral symptoms.

“Having a good sense of humor will go far,” advised Ms. Aro of her experience with caregiving. She also explained that they have a great personal support group that helps with the stress of caregiving.

Dr. Alva said there remains an unmet medical need for these patients. The Alzheimer’s Association recommends non-pharmacologic interventions as first-line therapy. When considering the use of antipsychotics, the Association advises the following decision-making considerations:

  • Identify and remove triggers
  • Assess severity and consequences of behavioral and psychological symptoms of dementia
  • Determine overall risk to self and others
  • Accept that this a short-term intervention that must be regularly reevaluated

There are no FDA-approved treatments for hallucinations and delusions, and all antipsychotics carry Black Box Warnings of increased risk of death, Dr. Alva advised. In addition, antipsychotics may be associated with adverse events in patients with dementia and have limited efficacy in this patient population.

Anticholinergic agents may be associated with clinical cognitive decline in these patients. Anticholinergic and antipsychotic drugs have an increased risk of dementia, he said. “That becomes problematic to the point that the American Geriatric Society Beers Criteria® addresses that anticholinergics, benzodiazepines, non-benzodiazepines, and antipsychotics should actually be avoided,” he said. Older adults with dementia also have polypharmacy, which could increase risks and comorbidities.

Ms. Aro noted that her mother’s delusions have gotten worse and become more frequent over time. She acknowledged that at some point they will need to move her mother into a long-term care facility, as has her father, who is the primary caregiver, is in his 70s.

“There is a significant unmet medical need for people experiencing dementia-related hallucinations and delusions,” Dr. Alva concluded. “We need to collectively do more.”

This industry symposium was supported by Acadia Pharmaceutics Inc.

Presentation: Hallucinations and Delusions Associated With Dementia-Related Psychosis – Understanding the Prevalence, Neurobiology, and Consequences. Presented at the Neuroscience Education Institute Max! Virtual Meeting, Nov. 5-8, 2020.