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Editors

TiinaTalaslahti
TuulaSaarela

Psychosis in the Elderly

Essentials

  • The psychotic illness, for example schizophrenia or delusional disorder, may already have started at a young age.
  • If the onset of schizophrenia is only in middle or old age, the term 'late-onset schizophrenia' or 'very-late-onset schizophrenia-like psychosis' is used.
  • Psychotic symptoms may occur in association with a number of organic and psychiatric conditionshttp://www.dynamed.com/condition/schizophrenia#DIFFERENTIAL_DIAGNOSIS.
    • Depression, mania and delirium
    • Metabolic and endocrinological disorders
    • Neurological diseases
      • Memory disease
      • CNS infections
    • Medication, poisonings and drug overdose
  • When antipsychotic medication is started, the lowest possible effective dose should be sought in order to avoid adverse effects.

Prevalence

  • The prevalence of schizophrenia in the elderly is about 1%. Less than 3% fall ill after the age of 60 years (very-late-onset schizophrenia-like psychosis).
  • Delusions can be found in 6% and the actual delusional disorder in 0.5% of the elderly.
  • In confusional states and in memory diseases, psychosis-like symptoms are found in 30-50% of the patients.

Clinical picture

  • In schizophrenia, the psychotic symptoms are often of long duration. Delusions are bizarre and diverse. Hallucinations are most often auditory hallucinations commenting on the patient's actions or having conversations with each other. In addition to the schizophrenic thought disorder, the elderly person may behave strangely and his/her emotions may appear flattened.
  • In addition, visual, tactile and olfactory hallucinations are common in people developing schizophrenia after the age of 60. Paranoia is severe. So-called partition delusion, where animals, people or substances come through walls or the ceiling occur in about 40% of patients.
  • In delusional disorder, the thoughts are distortedhttp://www.dynamed.com/condition/delusional-disorder#GUID-33BB15F1-7307-4D74-BEE2-64F9BB0766D4. The person is convinced of the correctness of his/her beliefs. Delusions can direct the course of action, the elderly person isolates him-/herself socially and may get into arguments (fall out) with the environment. Stealing and harassment delusions are typical. There may also be auditory hallucinations but they are not dominant.
  • In psychotic depression, the patient often has unrealistic trains of thought, feelings of guilt and odd delusions related to their bodily functions , such as believing that they have nonfunctional intestines http://www.dynamed.com/condition/depression-in-older-adults#TOPIC_FP2_R3J_X3B.
  • In manic psychosis, the patient's mood is elevated or irritable. The behaviour is uncontrolled and overexcited.
  • In memory diseases, symptoms most commonly include delusions of theft and visual hallucinations. Jealousy delusions may also occur. Recognition errors are common. Psychotic symptoms are often transient.

Clinical assessment

  • Onset and course of the symptoms: when were the psychotic symptoms first noticed, by whom and why?
  • Any history of psychotic illness or psychiatric treatment
  • Somatic diseases and drugs in use to treat them; current somatic symptoms
  • Any significant changes to living conditions or relationships
  • If at all possible, it is worthwhile complementing the patient's own account of his/her experience by finding out what the family members or persons taking care of the patient think about the situation. Elderly persons do not necessarily tell strangers about matters that they find embarrassing, but people close to them may hear about their experiences.
  • Objective assessment: e.g. could there really have been theft or some other genuine incident? Could there even have been maltreatment? What is the significance of the matter?
  • Why is an assessment necessary now? What is new in the situation?
  • For differential diagnostic alternatives to psychosis in the elderly, see Table T1.

Differential diagnostic alternatives to psychosis in the elderly

Differential diagnosisCharacteristics
DeliriumSudden onset of symptoms with disorientation and confusion
Organic psychosisOrganic (especially neurological, endocrinological and metabolic) symptoms in addition to psychosis
Drug effectMedication started or increased before the onset of symptoms
Memory disorderMemory impairment and extensive impairment in functioning
SchizophreniaLong history of mental illness, incoherent speech, odd behaviour
Delusional disorder or late-onset schizophrenia-like psychosisTightly logical, coherent delusional system focused on a specific theme, but otherwise relatively capable of functioning, no significant memory impairment. In schizophrenia-like disorder, additionally diverse psychotic symptoms.
DepressionDepressive mood, hopelessness, submission, and often somatic delusions
Old-age maniaJoyless overactivity and paranoid accusations, irritability
Paranoid personality disorderLong-term predisposition to distrustfulness and reserve, no clearly distorted sense of reality
No psychiatric diagnosisEnjoys being alone, avoids social contacts, no noteworthy problems with the environment, fends for him-/herself

Status

  • Is it possible to establish contact with the patient? Can the patient discuss the situation?
  • Thought content: what does the patient think, how does he/she draw conclusions, is he/she able to question his/her own account of events at all?
  • During the interview the patient may e.g. be asked how he/she has noticed or explained the unrealistic matter that he/she is reporting. At the same time, an attempt can be made to offer alternative explanations to what the patient reports.
  • Does the patient feel threatened?
  • Assessment of cognitive functions is important: how do memory and perception work?
  • Mood: is the patient depressed, full of action, fearful, anxious, defensive or aggressive? Does he/she have suicidal thoughts?
  • Level of functional capacity? Any changes?
  • Is the psychosis caused by an earlier diagnosed somatic illness or its medication?
  • Does the patient have acute or untreated somatic illnesses?

Assessment of the psychosocial situation and the need for treatment

  • Is the patient able to take care of himself/herself appropriately and is he/she able to cooperate?
    • Is the patient anxious, fearful, apathetic or agitated?
    • Is the patient unkempt, dirty, hungry? Is the accommodation adequate?
  • Are there signs that suggest abuse of alcohol or medications?
  • Is support available? Are the family members or neighbours exhausted or agitated? Is the patient willing to receive help (domiciliary services, home nursing etc.)?
  • Is the patient a danger to him-/herself or to others?
    • The patient may be dangerous if he/she feels threatened. A person with strong suspicions or jealousy is potentially dangerous.
    • Psychotic depression may involve self-destructive behaviour due to unrealistic thoughts of guilt.

Management

Immediate aims of management

Long-term aims of management

  • Reduction of mental suffering
  • Establishment and maintenance of the patient's trust and treatment compliance
  • Alleviation of somatic symptoms can help build up the treatment relationship. The patient should be supported in managing somatic diseases with the aim of moderately good tolerance of symptoms, as far as possible.
  • -Avoid referring to psychotic symptoms as a disease. Hallucinations and delusions are real for the elderly person. It is often advisable to look for ”honourable” ways out.
  • Reduction of isolation
  • The family should be supported and information provided to persons in contact with the patient. If the patient has grandchildren or great grandchildren, it is advisable to discuss with their parents whether they would like support in how to discuss the grandparent's symptoms with the children.
  • Support services and counselling should be offered. Focus should be on the patient's coping with everyday life. http://www.dynamed.com/management/nonpharmacological-interventions-for-schizophrenia#GUID-C2932585-FE63-4E7F-A404-62CF984DB245
  • The patient is guided and supported in choosing behavioural strategies that are tolerable both to him-/herself and to the environment.

Pharmacotherapy

  • It is advisable to postpone the initiation of drug therapy until the clinical diagnosis is more clearly defined, unless the patient's condition requires prompt initiation of medication.
  • The choice of drug should be based on individual assessment, considering the psychiatric or physical condition that underlies the psychotic symptoms. Other concomitant physical illnesses and the medications used for treating them also influence the choice of drugs.
  • Antipsychotic drugs are the primary choice in delusional and schizophrenia-type psychoses of the elderly http://www.dynamed.com/approach-to/first-episode-psychosis-approach-to-the-patient-1#TOPIC_GMX_MY3_GNB.
  • When medication is started, the lowest possible effective dose should be sought in order to avoid adverse effects. The dosage is generally lower in patients who develop a psychosis at an advanced age and can be as low as a quarter or half of the dose of working-age patients.
  • On the other hand, many patients who have fallen ill at a young age have used large doses of antipsychotics for years. Reduction of drug doses is often warranted at advanced age.
  • Clozapine (50-300 mg/day) has been shown to be the most effective antipsychotic drug, but there are limitations on its use, such as the need for regular blood test monitoring and the requirement of starting the medication under supervision by a specialist in psychiatry. Otherwise no significant differences in the efficacy of antipsychotic drugs have been found .
  • Other antipsychotic drugs used in schizophrenia and delusional disorder include risperidone (therapeutic dose 1-4 mg/day), quetiapine (200-600 mg/day), olanzapine (10-20 mg/day) and aripiprazole (10-20 mg/day)http://www.dynamed.com/condition/schizophrenia#TOPIC_SWD_1CN_CQBhttp://www.dynamed.com/condition/delusional-disorder#MEDICATIONS.
  • Long-acting injection of an antipsychotic drug may be practical for elderly persons with psychotic illness who are likely to stop their medication due to poor awareness of their illness.
  • When treating psychotic symptoms in a patient with memory disorder, the indications for medication should be assessed with particular care. Drug treatment should primarily be planned for a fixed period of time, e.g. for a maximum of 3-4 months, the response must be carefully monitored and the dosage is cautious. The dosage of risperidone is 0.25-2 mg/day. Other possible antipsychotic drugs include aripiprazole 2-7.5 mg/day, quetiapine 25-200 mg/day and olanzapine 2.5-10 mg/day, but these do not have an official indication in the treatment of behavioural symptoms of memory disorders.
  • Injections of long-acting antipsychotic drugs cannot be used in the treatment of a patient with memory disorder.
  • Primarily the second-generation antipsychotic drugs (risperidone, quetiapine, olanzapine and aripiprazole) should be used in the treatment of psychosis in the elderly, since they have, on average, fewer adverse effects than the traditional antipsychotics. The onset of action may be slower with the new antipsychotics compared with the traditional ones. If necessary, traditional haloperidol (0.5-2 mg/day or 2.5 mg intramuscularly once or twice) may, however, rapidly calm down an agitated patient.
  • The adverse effects of antipsychotic drugs http://www.dynamed.com/drug-review/adverse-effects-of-antipsychotic-medications#GUID-792989D3-4BDE-4AF1-8FAB-C3D1F7D4B23Fthat require special attention include extrapyramidal symptoms, tardive dyskinesia, excessive sedation, hypotonia, prolongation of QTc time, increased risk of falling, and the anticholinergic effects that also manifest as deterioration of cognitive functions. Unwanted weight gain may sometimes be a problem in the elderly too.
  • It should be kept in mind that antipsychotic drugs are probably associated with a slightly increased risk of stroke and death in persons with a memory disorder. The risk is dependent on the dose and the length of use.
  • If the psychotic symptoms are caused by depression, the patient should be treated with antidepressants combined with an antipsychotic drug and, additionally, possibly with psychiatric electroconvulsive therapy (ECT)http://www.dynamed.com/condition/major-depressive-disorder-mdd#ELECTROCONVULSIVE_THERAPY__ECT_.

Place of treatment and monitoring

  • Local primary care centre or ward
  • Home care: home visits of by a home nursing service doctor, a home help worker, a professional from the psychiatric outpatient services or outpatient clinic of geriatric psychiatry
  • Day hospital
  • Psychiatric hospital: acute care of elderly patients with severe symptoms or with treatment problems
  • Psychogeriatric nursing homes and psychogeriatric units of sheltered accommodation and nursing homes

When to consult with a psychiatrist?

  • The diagnosis is not clear.
  • Hospital treatment or compulsory psychiatric care is being considered
  • Medication is problematic
  • The long-term treatment plan is being revisited.