Psychotic and Bipolar Disorders: Behavioral Disorders in Dementia

Psychosis is one of the most common conditions in later life, with dementia being a main contributing factor. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), now categorizes the various types of dementia as neurocognitive disorders. Alzheimer disease is a common cause of dementia and psychosis. Psychosis also is seen in patients with vascular dementia and dementia with Lewy bodies. Psychosis can be primary, caused by a psychiatric disorder listed in the DSM-5, or secondary, due to a medical or neurologic condition. Approximately 60% of psychosis cases are secondary. Accurate diagnosis is important to rule out serious medical conditions or reversible etiologies. A careful history should be obtained and a thorough physical examination performed. Several risk factors make older adults prone to psychosis: sensory deficits, social isolation, and cognitive decline, along with other etiologies. Multiple potential risks and adverse effects are associated with drugs used to manage psychosis in elderly patients. Therefore, various guidelines recommend nonpharmacologic interventions as first-line treatment. When moderate or severe psychotic symptoms remain, drugs can be initiated as second-line treatment. Antipsychotic drugs have been shown to be effective in managing psychosis associated with dementia.