INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL 10: zyxw 743-752 (1995) REVIEW Psychotic Symptoms in Patients with Dementia CLIVE BALLARD* AND FEMI OYEBODE~ zyxwvu *Lecturer in Psychiatry, University zyxwvutsrq of Birmingham, ?Consultant Psychiatrist, Queen Elizabeth Psychiatric Hospital, Birmingham, UK SUMMARY The current article reviews the current state of knowledge pertaining to psychotic symptoms in patients with dementia, drawing on over 70 studies in this area. The majority of studies utilizing a purpose-designed structured instrument have found a prevalence of psychotic symptoms in excess of 60%. The annual incidence and resolution rates are, however, considerably lower, in the region of 2%. There is little consensus about which factors are of aetiological importance, although it does seem that those with a dementia of moderate severity have the highest prevalence. Perhaps the lack of clarity in this aetiological research partly relates to the limited attention paid to phenomenology. Some suggestions about future research directions which might improve our phenomenological understanding of these conditions are made. Psychotic symptoms are associated with considerable secondary morbidity including increased aggression, irritability and distress. KEY WORDS-psychotic symptoms; phenomenology; dementia Psychosis has often been used as a euphemism to describe a broad range of behavioural disturbances in the elderly with dementia. Fortunately, more rigorous definitions limiting the term psychosis to describe delusions and prominent hallucinations in clear consciousness have been used in the majority of recent studies. Several caveats have, however, been necessary, including the specification of a mini- mum duration which symptoms must last to qualify as psychotic symptoms to reduce the overlap with confabulation. Psychotic symptoms in dementia sufferers cause a great deal of distress to carers (Rabins et al., 1982), the patients themselves (Gilley et al., 1991) and are associated with a number of behaviour difficulties (Cooper et zyxwvuts al., 1991; Deutsch et al., 1991; Gilley et al., 1991; Rockwell et al., 1994). They reduce the likelihood of people continuing to live in their own homes (Steele et al., 1990) and are probably associ- ated with a greater speed of cognitive decline (Dre- vets and Rubin, 1989; Rosen and Zubenko, 1991; Forstl et al., 1993a). All of these factors make psy- chotic features in dementia sufferers an important area for study. Address for correspondence: Dr Clive Ballard, Queen Elizabeth Psychiatric Hospital, Mindelsohn Way, Birmingham B15 zyxwvutsr 242, UK. EPIDEMIOLOGY Estimates of the prevalence of psychotic symptoms in patients with dementia vary greatly from 11.7% (Rothschild, 1941) to 70.6% (Teeter et al., 1976). For each study reported, unless stated, the preva- lence of psychotic symptoms given is the period prevalence up to the time of the first assessment. Twelve studies, none of which used standardized criteria to diagnose psychotic symptoms, concen- trated on patients with presenile dementia (Coblentz et al., 1973; Rosenstock, 1970; Chen et al., 1991; Nott and Fleminger, 1975; Liston, 1979; Sim and Sussman, 1962;Sim et al., 1966; Goodman, 1953; Sjogren et al., 1952; Eiden and Lechner, 1950; Rubin et al., 1993; Stern et al., 1987), finding a prevalence between l8Y0 (Sim and Sussman, 1962; Simetal., zyxw 1966)and41.2%(Rubin,etal., 1993).The lack of standardized instruments and operational criteria limits the amount of useful information which can be abstracted from these studies other than the existence of psychotic symptoms as a common problem. Thirty-six studies reported patients largely over the age of 65. Five of these did not use standardized criteria for either the diagnosis of dementia or psy- chotic symptoms (Berrios and Brook, 1985; Uriate Received 30 June 1994 Accepled 4 October 1994 CCC OS85-6230/95/090743-10 zyxwvutsr 0 1995 by John Wiley zyxwvutsrqp & Sons, Ltd.