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What Is Dementia Related Psychosis

Proposed Mechanism For Drp

Exploring Guidelines and Therapeutic Strategies for the Treatment of Dementia-Related Psychosis

The proposed mechanism for DRP is believed to involve a common corticallimbic psychosis pathway . Cortical GABAergic interneuron or NMDA receptor dysfunction is hypothesized to result in loss of inhibitory tone, leading to hyperactivity of glutamatergic neurons that signal to the VTA. Alternatively, excessive signaling via 5-HT2A receptors on pyramidal glutamate neurons can lead to hyperactive glutamatergic neurons that signal to the VTA. Sustained hyperactive glutamatergic signaling then leads to mesolimbic dopamine pathway hyperactivation, resulting in hallucinations and delusions. Excess signaling via 5-HT2A receptors in the visual cortex may be responsible specifically for visual hallucinations.Reference Hacksell, Burstein, McFarland, Mills and Williams66,Reference Kometer, Schmidt, Jancke and Vollenweider70,Reference Braak and Braak87

The corticallimbic psychosis pathway can be triggered in a variety of different ways across dementias based on which neurons are lost or damaged and which signaling pathways become disordered but appears to be responsive to serotonin modulation. Cortical GABA interneuron dysfunction, excess serotonin, cortical 5-HT2A receptor upregulation, excess striatal dopamine, striatal D2 receptor upregulation, and excess glutamate signaling all have the potential to contribute to pathway dysfunction.

Dementia: What Is Dementia

More than 2 million Americans have dementia-related psychosis. If you have a loved one who has dementia, you know that it can be a scary condition for both those going through it and for their caregivers. When they have to deal with psychotic episodes, too, it can be even more unnerving.

But instead of thinking psychotic features as this taboo, icky subject, I just want people to understand that its a normal manifestation of these illnesses. An expected manifestation. A disease talking, says Pierre N. Tariot, the director of the Banner Alzheimers Institute in Phoenix, AZ.

Your loved one is not crazy. Theyre ill. Their brain isnt functioning properly. And we can evaluate that, and we can help you understand that. And we can help relieve the distress yours and your loved ones.

Do You Believe There Will Need To Be Further Analysis Into How This Therapy Treats Psychosis Within Each Of Those Dementias Individually

Yes, I think we will need to investigate more about how each of the dementias themselves responds to pimavanserin. We do have data already on Parkinson disease psychosis because pimavanserin is approved for Parkinson disease psychosis, but we need additional data on Alzheimer disease, vascular dementia, dementia with Lewy bodies, and Frontotemporal dementia. Those are all dementias that are more uncommonexcept for Alzheimer disease, of course. So, we need additional data on these other dementia states.

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Hallucinations Distorted Senses Common Symptoms Of Dementia

Brandt T, et al. Poster 47164. Presented at: Alzheimers Association International Conference. July 27-31 .

Brandt T, et al. Poster 47165. Presented at: Alzheimers Association International Conference. July 27-31 .

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Individuals with dementia-related psychosis commonly experience visual hallucinations, auditory hallucinations and distortion of senses, according to data presented at the Alzheimers Association International Conference 2020.

ACADIA is committed to understanding the lived experience of people with dementia-related psychosis, for whom there are no approved treatments,Teresa Brandt, PhD, executive director of regulatory affairs at ACADIA Pharmaceuticals, told Healio Psychiatry. The aim of this study was to capture the lived experience of people with dementia-related psychosis, either directly or via caregiver input, which can be exceedingly difficult in patients with cognitive decline who may no longer be able to act independently and raise their own voice. Although there are numerous publications noting the prevalence of psychotic symptoms across dementias, what was missing was an understanding of the specific impacts that hallucinations and delusions have on people living with dementia.

Teresa Brandt

Drugs Improving Sleep Quality Displaying Various Mechanisms Of Action


Noradrenergic and Specific Serotonergic Antidepressant: Mirtazapine

Nocturnal sleep quality may contribute to the onset of behavioral problems in patients with dementia . Clinical observations suggested that agitative behavior in patients with dementia might be caused by sleep disturbances . In this regard, it has been proposed that both conditions could be effectively addressed by a drug that displays anxiolytic as well as sleep-promoting activity .

Mirtazapine is an antidepressant with sedative properties and an ability to promote sleep . It interacts with several types and subtypes of receptors including serotonin 5-HT2AR and 5-HT3R, alpha-2 adrenoceptors, and H1R . The unique pattern of receptor modulation by mirtazapine not only ameliorates psychiatric symptoms but also helps to improve sleep quality . The first pilot study evaluating the effect of mirtazapine on AD-related agitation was a 12-week open-label, prospective study that included 16 patients who had clinically significant agitation . The authors observed a significant reduction in agitation in the patients treated with mirtazapine compared with pre-treatment with mirtazapine . These encouraging data prompted the initiation of a larger phase III, pragmatic, multi-center, double-blind, placebo-controlled, randomized study , which is currently recruiting 222 patients to evaluate the safety and effectiveness of mirtazapine in reducing AD-related agitation .

Chemical structure and binding profile of mirtazapine

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Drugs Affecting Glutamatergic Neurotransmission

Metabotropic Glutamate 2 Receptor Agonist: LY2812223

In the early 1990s, it was first proposed that dysfunction in glutamatergic neurotransmission could be implicated in mental disorders . Therefore, it was postulated that modulation of glutamatergic activity may constitute a novel nondopaminergic strategy for the treatment of psychosis . Additionally, previous studies highlighted the activation of glutamate receptors exerts neuroprotective and memory-enhancing effects in animal models, which might be particularly beneficial to patients with dementia . Eli Lilly and Company discovered LY2812223 , a mGluR2 agonist . LY2812223 was found active in an animal model of psychosis, sensitive to mGluR2 . Unfortunately, in the pharmacokinetic studies, LY2812223 showed a poor oral bioavailability . However, this did not limit the further development of the mGluR2 agonist for the treatment of mental disorders. Low bioavailability of LY2812223 was overcome by designing its alanine prodrug MP-101 . MP-101 is administered orally and absorbed in the gastrointestinal tract through active transport and then, it is rapidly hydrolyzed to .

Chemical structure and metabolic activation of MP-101, a prodrug of . cAMP cyclic adenosine monophosphate, hmGluR2 human metabotropic glutamate receptor type 2

Inhibitors of D-Amino Acid Oxidase

This Condition Can Also Cause Delusions

Delusions are fixed beliefs that are factually incorrect. A common delusion is one of theft, when a person believes that someone, even a loved one, is stealing their money, jewelry, or other valuables, Dr. Foff says. The patient may fear they are being abandoned by their family or that their spouse is having an affair. Even when this is demonstrably untrue, its very difficult to get someone to abandon this belief. Their brain has convinced them of a differentif untruereality.

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Jeffrey Cummings Md Scd On Pimavanserins Potential In Dementia

The professor of brain science and director of the Chambers-Grundy Center for Transformative Neuroscience at UNLV spoke to the recently published HARMONY phase 3 study data.

Recent data published in the New England Journal of Medicine suggest that patients with dementia-related psychosis who had a response to pimavanserin had a lower risk of relapse with continuation of the drug than with discontinuation.1 The trial was originally halted due to efficacy threshold achievement.2

Ultimately, of the 351 patients included in the analysis, 217 reported a sustained response. Of those, 105 were assigned to receive pimavanserin and 112 to receive placebo, with relapse occurring in 12 of 95 patients in the pimavanserin group and in 28 of 99 in the placebo group . Treatment with the study drug reduced psychosis relapse risk by 2.8-fold compared to placebo in the double-blind period .1

Notably, Acadia submitted a supplemental new drug application for the agent in July 2020 but received a complete response letter in April 2021 after the FDA determined that the drug could be approved in its present form. A lack of statistical evidence in some of the subgroups of dementia, and insufficient numbers of patients with certain less common dementia subtypes was cited as lack of substantial evidence of effectiveness to support approval.3

Drug Might Be Safer For Dementia Psychosis

Clive Ballard, MD: Pimavanserin In Patients With Dementia-Related Psychosis

HealthDay Reporter

WEDNESDAY, Feb. 14, 2018 — The “overmedication” of agitated dementia patients — with the use of powerful antipsychotic drugs — is an ongoing issue in U.S. health care.

Now, British researchers say they may have found a medicine that helps ease those symptoms, but in a much safer way.

The newer antipsychotic pimavanserin appears to ease psychosis symptoms in people with Alzheimer’s disease without the serious side effects caused by current antipsychotics, according to a study funded by the drug’s maker.

According to the researchers, psychosis affects up to half of the 45 million Alzheimer’s patients worldwide, and that percentage is even higher among patients with other types of dementia.

Currently, there is no approved safe and effective treatment for this common symptom. Standard antipsychotics are widely used, but they can also raise the risk of falls, stroke and even death, and have been linked to a doubling in the rate of brain function decline, according to the study authors.

One study released earlier this month found that, given these concerns, the percentage of long-term U.S. nursing home residents receiving antipsychotic drugs fell from about 24 percent in late 2011 to less than 16 percent in 2017. But advocates for patients say the rate should still be much lower.

“Psychosis is a particularly terrifying symptom of Alzheimer’s disease,” explained Clive Ballard, the lead author of the current study.

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Compounds In The Early Stage Of Development

We additionally searched for literature data associated with the identified compounds in the early stage of development , published from 2014 to the present day to obtain the most recent overview covering the last 5;years, using the compounds name and other keywords such as Alzheimers disease and dementia or aggression or psychosis. We used PubMed, ScienceDirect, GlobalData, and Google Scholar databases for our search . If data regarding the identified compounds were not published, we searched the websites of pharmaceutical and biotech companies responsible for the compounds development. Several molecules that matched the selection criteria were identified, which are described in detail below.

Drugs Affecting Serotonergic Neurotransmission

Serotonin 5-HT2A Receptor Inverse Agonist: Pimavanserin

Among the various molecular targets considered as potential treatments of dementia-related psychosis or agitation/aggression, serotonin receptors have come into the limelight. Age-related decline in serotonin function has been linked with aggressive behavior in AD . Specifically, a reduced density and polymorphism of 5-HT2AR have been observed with the onset of aggression and psychosis in patients with dementia . Therefore, modulation of the activity of 5-HT2AR seems to be a promising therapeutic strategy for reducing psychiatric symptoms that matches closely with the disease pathology.

Structure and receptor profile of pimavanserin

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What To Watch For

It seems pretty clear that if a person with dementia says that a dead spouse came to visit, or that the people in the nursing home are conspiring to poison the food, that’s a sign that something’s up, and the person’s care team needs to know about it. But people with symptoms of psychosis sometimes aren’t very forthcoming with that information. Even caregivers may keep things like that to themselves.

“I would tell people, I do tell people ⦠they may feel fear or shame or stigma around these symptoms: Please don’t,” Ismail says. “It doesn’t reflect on a loved one with dementia, it doesn’t reflect on you. These are just symptoms of the changing brain. It doesn’t mean they’re a bad person, it doesn’t mean they’re ‘crazy.’ None of that.

“Just like the brain is changing and causing them to forget, the brain is changing and causing them to believe things that might not be real.”

In addition to some people’s unwillingness to be honest about hallucinations or delusions, some doctors or professional caregivers just don’t have the time, experience, or expertise to dig into symptoms to see if they’re a sign of psychosis or something else. Combined with the many symptoms of dementia, a diagnosis is not always clear.

” rarely happen in isolation,” Ismail says. “You can have psychotic symptoms with agitation, you can have agitation with psychotic symptoms. One might be primary. For some, as progresses, they can get them all.”

Proposed Mechanism Of Action Of Pimavanserin

Dementia and Related Psychosis: Should Antipsychotic Drugs ...

Across the underlying causes of corticallimbic psychosis pathway hyperactivation, 5-HT2A receptor antagonism represents a common point of regulation and for treatment intervention with antipsychotics.Reference Hacksell, Burstein, McFarland, Mills and Williams66 Pimavanserin is a selective serotonin inverse agonist/antagonist at 5-HT2A receptors, with 40-fold less activity at 5-HT2C receptors and no affinity for dopaminergic, histaminergic, muscarinic, or adrenergic receptors, and is proposed to act as a targeted serotonergic modulator of circuits .Reference Hacksell, Burstein, McFarland, Mills and Williams66 Pimavanserin is thought to reduce the activity of these receptors to below basal levels and regulate the effects of both cortical GABAergic deficits and excess cortical serotonergic signaling. This is posited to decrease visual hallucinations and attenuate glutamate signaling to the VTA and mesolimbic pathway, further decreasing delusions and hallucinations.

Figure 2. Pimavanserin-mediated 5-HT2A receptor inhibition: hypothesized modulation of signaling through a variety of neurotransmitters. Through 5-HT2A antagonism/reverse agonism, pimavanserin is proposed to act as a targeted serotonergic modulator of circuits, mitigating the effects of GABAergic deficits and excess serotonergic signaling, while also reducing hyperactive glutamatergic signaling and mesolimbic pathway activation.

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What Is Psychosis In Dementia

Psychosis is a state of mental illness in which a patient appears to have lost contact with reality, or the “reality” the patient is experiencing is very different or distorted from actual reality. Psychotic symptoms may be present all the time or may be episodic. Dementia is an umbrella term describing a wide range of symptoms linked to progressive deterioration in mental functions, such as language, memory and judgment. It often affects emotional behavior and responses.

Psychosis in dementia is common as dementia progresses. Frequently exhibited symptoms of psychosis in dementia include auditory and visual hallucinations. Auditory hallucinations mean the patient is hearing voices that are not there. Visual hallucinations mean the patient is seeing things others are not. These symptoms can be very distressing for the patient.

Delusions are a common symptom of psychosis in dementia. Delusions are false ideas that the patient very firmly believes. In dementia, this can involve the patient believing he is a child and caregivers are parents, that he is not old but a young adult going about daily life, or that he is a prisoner. Another common delusion is believing that personal property is being stolen.

Approaches For The Caregiver

Caregivers of patients with dementia should be educated about the disease process and the disease manifestations being exhibited. Attendance at support group meetings, personal discussion with the physician, and resources such as The 36-Hour Day7 and the Alzheimers Association may be helpful. In most situations, coping strategies include remaining calm and using touch, music, toys, and familiar personal items. Helping the caregiver understand the lack of intentionality of the behaviors is essential.

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Did Any Of The Data From Harmony Stand Out As Particularly Surprising Or Exceptional In Any Way

Yes, one of the things that really excited me about this trial is the design, which is a randomized discontinuation trial. All patients are put on pimavanserin, and then if they respond to pimavanserin, they’re either randomized to placebo or to continuing pimavanserin to see whether the relapse of the psychosis was greater in the placebo group than in the pimavanserin group. And the result was so positive that the trial was stopped early. That’s a very rare event in neurological trials, that the interim analysis revealed such a robust finding that the trial can be discontinued at that time.

Neurologylive: How Would You Describe The Current State Of Care For Psychosis In Dementia

James Leverenz, MD: Therapeutic Options in Dementia And Related Psychosis

Jeffrey L. Cummings, MD, ScD: Currently, although psychosis is a common problem in Alzheimer disease and other dementias, there are no approved therapies for the treatment of psychosis in dementia. The HARMONY trial of pimavanserin treatment of dementia-related psychosis was a unique trial, both in terms of its design, but also in terms of including 5 types of dementia, and showing their response, or the response of this group of dementias, to treatment with pimavanserin.

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Psychosis Is Likely Caused By Serotonin Changes In The Brain

Serotonin is this neurotransmitter that truly plays a critical role in multiple central nervous system or brain disorders, explains Richard Isaacson, M.D., a neurologist at New York-Presbyterian/Weill Cornell Medical Center and founder of the Alzheimers Prevention Clinic at Weill Cornell Medicine in New York City. Its used to communicate from one brain cell to another. When serotonin-influenced neurotransmitters become hyperactive, this disrupts the brains ability to communicate crucial information about what is happening around you. This can lead someone to have sensory experiences that dont make logical sense, like having a conversation with a long deceased loved one.

Neurotransmission Alterations Across Dementias

While the strength of the evidence varies across these dementias, all have been associated with alterations in neurotransmission which have the potential to impact the corticallimbic psychosis pathway. Each of these conditions is highly heterogeneous and the likelihood an individual patient will develop psychosis varies greatly. Further research is required to confirm how etiological factors, such as the anatomical locations of neurodegeneration, compensatory mechanisms, and genetic influences contribute to the development of psychosis.

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