Functional Mental Illness in Later Life: Psychosis Neil Robertson Slides adapted from Dr Suzanne Reeves, Senior Clinical Lecturer, IOP.

Psychosis Psychosis is an umbrella term for a number of psychotic illnesses that include: Drug induced psychosis Organic psychosis Bi-polar disorder Schizophrenia Psychotic depression Schizo-affective disorder (Taken from EPPIC)

Psychosis is characterised by: Hallucinations – sensory perceptions in the absence of external stimuli – Types? Delusions – a belief held with strong conviction despite evidence to the contrary Formal Thought Disorder - presenting with incomprehensible thought patterns and/or language Catatonia - state of neuro-genic motor immobility, and behavioural abnormality manifested by stupor, over-activity or rigidity

Negative symptoms Blunted affect Poverty of speech Anhedonia Lack of desire to form relationships Lack of motivation

Psychotic Depression Prevalence ~2% -35% of older inpatients - 5% of young adults Delusions - persecutory, hypochondriacal, poverty Hallucinations - 2 nd person auditory, olfactory, gustatory Co-morbidity -  physical co-morbidity in older compared to young adult patients

Alcoholic Hallucinosis History of excessive alcohol intake 2 nd person auditory hallucinations most common Persecutory ideas/ideas of reference ~ co-morbid depressive symptoms ~ cognitive impairment

Onset after 60 non-organic, non-affective Late-onset schizophrenia Late life psychosis

Schizophrenia

Classification and Incidence Late-onset schizophrenia (LOS) - illness onset > 40 yrs per population per year Very-late-onset schizophrenia-like psychosis (SLP) - illness onset > 60 yrs per population (Holden et al, 1987)

Criteria for SLP Onset > 60 years Presence of fantastic, persecutory, referential, or grandiose delusions +/- hallucinations Absence of primary affective disorder MMSE >24/30 No clouding of consciousness No history of neurological illness/alcohol dependence Normal blood chemistry (see Howard et al, 2000)

People with SLP have all the symptoms of schizophrenia except for... Formal thought disorder Negative symptoms

Plus some extra symptoms…. Complex visual hallucinations Partition delusions

Phenomenology of SLP Non-verbal auditory hallucinations 70% 3rd person auditory hallucinations 50% Hallucinations in other modalities 30% Delusions - persecution 85% reference 75% misidentification 60% partition 70% Formal thought disorder, negative symptoms rare (<5%) and may represent misdiagnosed cases

Partition Delusions Watched /overheard through partition 40% Human intruder to home +-theft 34% Non-human intrusion – gas/radiation 30% Somatic effect of intrusion 20%

Howard, R et al (1992). Int J Geriatr Psychiatry 7; PERMEABLE WALLS, FLOORS, CEILINGS AND DOORS. PARTITION DELUSIONS IN LATE PARAPHRENIA A partition delusion is the belief that people, objects or radiation can pass through what would normally constitute a barrier to such passage. These delusions have been reported to be common in late paraphrenia and late-onset schizophrenia. Such partition delusions were found in 68% of 50 patients with late paraphrenia, but only in 13% of patients with schizophrenia who had grown old and in 20% of young schizophrenics.

SLP: Cognitive Outcome SLP: Cognitive Outcome 25%  cognitive impairment consistent with a diagnosis of dementia within 3 years (Holden 1987, Reeves 2001) 75% stable cognitive deficits

Risk Factors for SLP Age: incidence  by 11% for every 5 yr  in age beyond 60 years Age: incidence  by 11% for every 5 yr  in age beyond 60 years 4 x higher risk compared to men Female Gender: 4 x higher risk compared to men - not explained by higher proportion of ‘older’ women - ?loss of protective effect of oestrogen post menopause Sensory Deficits : Auditory 40%, Visual 20% Genetic Factors: more likely to have a FH of affective disorder Pre-morbid Personality : paranoid, depressive, anxious or schizoid traits

Social Cognition Deficits Deficits in social cognition reported in young adults with schizophrenia Believed to represent a reduced ability to process context-based information People with SLP report similar deficits in ‘executive function’ as young people with schizophrenia Social processing - mentalising (understanding the intentions of others) - also affected in SLP (Moore et al, 2006)

Other possible risk factors for SLP As yet unidentified biological factor  vulnerability towards SLP Genetic loading for affective disorder Female sex Increasing age Migrant status Unmarried state and isolation Specific deficits in social cognition

Treatment of SLP Summary: Pharmacological: No RCTs but observational studies suggest that low dose antipsychotic medication is effective Psychosocial: Observational studies suggest that engagement with a keyworker and increasing positive social interactions may improve outcome

Psychosocial aspects of treatment Aim to increase positive social interactions - Correcting sensory deficits may reduce the risk of misinterpretation of others’ - Increase social outlets,encourage attendance at hospital/luncheon club - Allocating a keyworker/care co-ordinator to facilitate this and to monitor mental state

When to Intervene.. 3 reasons to intervene: When symptoms are causing distress to the point where the person is at risk of (i) Self-harm (ii) Self-neglect (iii) Retaliation against the ‘perpetrator’ When not to intervene: When the person is refusing treatment AND the risks are low in terms of self or others.