Research Article| Volume 26, ISSUE 3, P304-313, March 2018

Psychosis and Clinical Outcomes in Alzheimer Disease: A Longitudinal Study

Published:October 20, 2017DOI:


      • Psychotic symptoms are common in Alzheimer disease, affecting half of the patients in this sample over a three year period.
      • Both delusions and hallucinations are associated with greater cognitive and functional impairment, dementia severity, and caregiver burden.
      • The presence of both delusions and hallucinations is associated with worse outcomes than the presence of only one of these symptoms.
      • Delusions, both by themselves and in combination with hallucinations, predict institutionalization; use of antipsychotic medication predicts mortality.
      • The findings highlight the challenges of managing psychosis in Alzheimer disease given its poor prognosis and the mortality associated with antipsychotic medication.


      Psychotic symptoms are a common feature in Alzheimer disease (AD), occurring in approximately 40% of patients. These symptoms are associated with worse clinical outcomes. Comparatively little research, however, has distinguished delusions and hallucinations, which may have distinct clinical, neuropathological, and genetic correlates. To address this, the current study examined the clinical outcomes associated with delusions and hallucinations in AD.


      Three-year observational study.


      Nine memory clinics in Australia.


      A total of 445 patients with AD.


      Measures of neuropsychiatric symptoms, dementia severity, cognition, function, caregiver burden, and medication use were completed annually for 3 years with additional assessments at 3 months and 6 months in the first year. Mortality data were obtained from state registries approximately 5 years after the study.


      Of 445 patients, 102 (22.9%) developed only delusions, 39 (8.8%) developed only hallucinations, and 84 (18.9%) developed both symptoms. Delusions and hallucinations were both associated with greater dementia severity, poorer cognition and function, higher levels of other neuropsychiatric symptoms, and greater caregiver burden. The presence of both symptoms was associated with worse outcomes than only one of these symptoms. Delusions, both by themselves and in combination with hallucinations, predicted institutionalization. Antipsychotic medication use predicted mortality.


      Delusions and hallucinations independently and in combination are associated with poor clinical outcomes. The findings highlight the challenges managing these patients, particularly given the high levels of caregiver burden associated with psychotic symptoms and the likely mortality arising from antipsychotic medication.

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      Linked Article

      • Psychosis in Neurodegeneration: Relating Phenomenology to Pathology and Prognosis
        The American Journal of Geriatric PsychiatryVol. 26Issue 3
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          Psychosis is a uniquely disabling complication of several neurodegenerative diseases. In recent years it has emerged as the focus of an increasing number of clinical investigations, approached from both pathological and phenomenological perspectives in several disease-specific contexts. One might imagine an eventual paradigmatic conception of psychosis that explicates its mechanistic underpinnings across multiple diseases. This is likely to be overly simplistic, given the heterogeneous nature of the symptoms that are often classified under the heading of psychosis, as well as the complexity of networks involved in generating perceptions and beliefs that are not congruent with reality.
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