The DRP3 Is a New Screening Tool to Identify Possible Psychosis in Dementia

Hallucinations and delusions are common in dementia and may be comorbid or part of the disease process (ie, dementia related psychosis [DRP]). DRP occurs in 30% of people with any type of dementia, 40% of those with Alzheimer disease and 70% of dementia with Lewy bodies.

DRP symptoms often go unrecognized and untreated and are often a reason for institutionalization. The person having delusions or hallucinations may not realize what is happening. Caregivers, including physicians may also be unaware that these symptoms are driving troubling behaviors because busy clinicians have little time to take thorough psychiatric histories. 

A panel of experts* developed a 3-question screening tool, the DRP3, which is not a rating scale to diagnose or characterize psychosis. Rather, a positive screen tells the clinician or caregiver that psychosis symptoms are present and further assessment for DRP is warranted. The DRP 3 asks:

1.    Is the person increasingly suspicious or paranoid? 
2.    Is the person hearing, seeing, or experiencing things that are unusual?
3.    Is the person believing or thinking things that are unusual or strange?

The DRP3 ws developed with a content validation exercise comparing DRP3 questions with the Scale for Assessment of Positive Symptoms – Hallucinations + Delusions (SAPS-HD) and to hallucination- and delusion-related questions of the Neuropsychiatric Inventory Questionnaire (NPIQ) and the International Psychogeriatric Association Criteria (IPA) for Psychosis in Major and Mild Neurocognitive Disorders. Content validity was demonstrated, and inter-rater reliability had statistical significance (P<.001). 

The DRP3 was retrospectively applied to the participants in the HARMONY trial (NCT03325556) of pimavanserin (Nuplazid; Acadia Pharmaceuticals, San Diego, CA), which, at present, is approved only for the indication of hallucinations and delusions associated with Parkinson disease psychosis but is also being evaluated for DRP. The DRP3 correctly identified all participants' baseline characteristics as potential DRP. 

Jeffrey Cummings, MD, ScD, Joy Chambers-Grundy Professor of Brain Science and director, Chambers-Grundy Center for Transformative Neuroscience, University of Nevada Las Vegas and a member of the panel said, "Overall the instrument performed very well showing that the DRP is valid and reliable. We would like to see its performance in a real-world setting, such as putting it into the hands of caregivers to see whether they themselves can pick up possible psychosis, allowing them to have a knowledgeable discussion with health care professionals about possible DRP."

If a patient is found to possibly have psychosis, Dr. Cummings suggested the next steps would rule out urinary tract infection, anemia or electrolyte imbalances, and other metabolic abnormalities with urine and blood testing. An MRI may be useful to rule out stroke or other intracranial disease. 

If there is a positive diagnosis for DRP, physicians and care team members can assess how troublesome those are to patients and caregivers and whether or not to treat DRP. Nonpharmacologic options should be tried first, but antipsychotic medications may be needed. 

The DRP3 was presented at the Alzheimer's Association International Conference, July 26-30, 2021.

*members of the panel, convened by Acadia Pharmaceuticals, were not compensated in any manner for their participation