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TiinaTalaslahti

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 also in association with a number of organic and psychiatric conditions.
    • 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%. Of all patients diagnosed with schizophrenia, fewer than 3% fall ill after the age of 60 years (very-late-onset schizophrenia-like psychosis, VLOSLP).
  • 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

  • See also the table T1.
  • In schizophreniaSchizophrenia, 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 distorted. 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.
  • In manic psychosis associated with bipolar disorder Bipolar Disorder, 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?
  • History of psychotic illnesses 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?
  • Differential diagnostic investigations are particularly necessary in first psychosis.
    • TSH,albumin-corrected calcium, basic blood count with platelet count, transcobalamin II-bound vitamin B12, folate, ALT, plasma creatinine, sodium, potassium, glucose, HbA1c; PEth and carbohydrate-deficient transferrin (alcoholconsumption), ECG
    • Head imaging: MRI, secondarily CT
    • Cognition: memory screening (MMSE, CERAD, MoCa) or neuropsychological examination Clinical Assessment of Memory Impairment
  • 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 disorderTightly logical, coherent delusional system focused on a specific theme
Relatively capable of functioning, no significant memory impairment
Late-onset schizophrenia-like psychosisDiverse 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, memory and perceptual ability
  • Mood: is the patient depressed, full of action, fearful, anxious, defensive or aggressive? Does he/she have suicidal thoughtsA Patient at Risk of Suicide?
  • Functional capacity and its changes
  • Somatic status
    • 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?
    • Anxiety, fearfulness, apathy, agitation
    • Neglect, dirtiness, starvation, adequate accommodation
  • Signs that suggest abuse of alcohol or medications (blood PEth, serum carbohydrate-deficient transferrin)
  • Available support and its reception
    • Family members or neighbours (assessment of coping)
    • Domiciliary services, home nursing etc.
  • Assessing the risk to the patient him-/herself and others
    • A person who is intensely suspicious, feels threatened or is jealous can be a danger to him-/herself or others.
    • Psychotic depression may involve self-destructive behaviour due to lack of prospects or unrealistic thoughts of guilt A Patient at Risk of Suicide.

Management

Immediate aims of management

  • Management of the acute crisis and securing of immediate treatment
  • Optimization of the somatic condition; treatment of any underlying organic illness behind the psychotic symptoms and assessment of medication
  • Relieving anxiety and feeling of being threatened
  • If the patient is a danger to him-/herself or to the environment, compulsory psychiatric treatment should be resorted to if necessary.

Long-term aims of management

  • Reducing mental suffering, establishment and maintenance of the patient's trust and treatment compliance, reduction of isolation
    • 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.
  • 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.
  • Supporting the family and providing information to persons in contact with the patient
    • If the elderly person's family community includes minors, it is advisable to find out whether their parents would like support in how to discuss the grandparent's symptoms with children.
  • Offering support services and counselling, focus on coping with everyday life
    • 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.
  • 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.
  • Manyelderly patients with psychosis 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.
  • In long-term psychotic illnesses, clozapine (50-400 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. Therefore, prescribing in psychotic disorders is limited to psychiatrists and physicians who are familiar with clozapine treatment.
  • Other antipsychotic drugs used in schizophrenia and delusional disorder include risperidone (indicative therapeutic dose 1-4 mg/day), quetiapine (50-400 mg/day), olanzapine (5-10 mg/day) and aripiprazole (5-15 mg/day).
    • No significant differences in efficacy have been found.
    • 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. Antipsychotic medication should be used only to treat severe psychosis symptoms. 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 2.5-10 mg/day, quetiapine 25-150 mg/day and olanzapine 2.5-10 mg/day, but these do not have an official indication in the treatment of neuropsychiatric symptoms associated with 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.
    • If necessary, traditional haloperidol (0.5-2 mg/day or 2.5 mg intramuscularly once or twice) may rapidly calm down an agitated patient.
    • Other possible short-acting medication injections for use in acute situations (mainly in psychiatric treatment) are olanzapine 5-10 mg intramuscularly and aripiprazole 5.25-9.75 mg intramuscularly.
  • The adverse effects of antipsychotic drugs that require special attention include extrapyramidal symptoms (stiffness, motor retardation and 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.

    References

    • González-Rodríguez A, Seeman MV, Izquierdo E, et al. Delusional Disorder in Old Age: A Hypothesis-Driven Review of Recent Work Focusing on Epidemiology, Clinical Aspects, and Outcomes. Int J Environ Res Public Health 2022;19(13) [PubMed]
    • Shobassy A. Elderly Bipolar Disorder. Curr Psychiatry Rep 2021;23(2):5 [PubMed]
    • Howard R, Rabins PV, Seeman MV, et al. Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. The International Late-Onset Schizophrenia Group. Am J Psychiatry 2000;157(2):172-8 [PubMed]
    • Cummings J, Pinto LC, Cruz M, et al. Criteria for Psychosis in Major and Mild Neurocognitive Disorders: International Psychogeriatric Association (IPA) Consensus Clinical and Research Definition. Am J Geriatr Psychiatry 2020;28(12):1256-1269 [PubMed]