1. Psychosis in the Elderly
Dr Anna Beaglehole,
SpR in Old Age Psychiatry

2. Objectives Definitions Epidemiology Differential diagnoses
Clinical features of main conditions
Evidence for management

3. What is Psychosis?
FISH: ‘an individual who lacks insight…and constructs a false environment out of his subjective experiences’
loss of touch with reality
Impaired perception - delusions, hallucination
lack of insight

4. Definitions
Delusions
Hallucinations

5. Psychotic symptoms Seen in wide range of conditions
Constellation of sx vary with the underlying condition
Associated with aggressive behaviour
Source of distress to caregiver
Neglect and elderly abuse
Persistent sx -institutionalisation

6. Differential diagnosis
‘FUNCTIONAL’
Graduate schizophrenia
Late onset schizophrenia
Affective disorders
Delusional disorder
ORGANIC
Delirium
Medical condition
Drug induced
Substance Misuse
Neurodegenerative
Alzheimer’s
Vascular dementia
DLB, PD

7. Epidemiology of Psychotic Symptoms
Point prevalence of paranoid ideas 5%, mostly dementia
Community prevalence %
Nursing Home 10% - 60%
Karim S, Byrne EJ, APT 2005

8. Psychosis in Old Age: Epidemiology
1st onset psychotic Sx
392, 70-90yr F/up 20y
8% developed psychotic sx
20% of those who survived to 85 years
Ostling et al 2007; Int J Geratr Psych:22:

9. Functional: Schizophrenia

10. Historical Perspective
Paraphrenia >40, Kraeplin 1909
Late onset schizophrenia, Bleuler 1943
Late paraphrenia >60 Roth 1952
International consensus 1998
LOS (40-59y)
VLOSLP (60+)
Classification System

11. Graduate schizophrenia
Living in community
Poor self care and nutrition
Apathy, amotivation
Negative sx predict worse overall outcome
Well developed delusional system
Cognitive function deteriorates
Even more marked when institiutionalised

12. VLOSP: Case example Active, cog intact GP alerted Intruder into house
Multiple locks
Elaborate
Brief respite fr sx
Poor insight

13. Clinical Features of New Psychosis
Insidious onset
Delusions
Persecution
Focused, intrusions
Partition delusions 2/3
Hallucinations
Auditory: 3rd derrog
Tactile and olfactory
VH rare
Relative preservation of cognition
Lack of insight
Depression
Social isolation
Less genetic contribution
Sensory impairment

14. Treatment: Cochrane
Randomised trials evaluating antipsychotic drugs for schizophrenia and Schizophrenia-Like-Psychoses
3 small RCT (n=252)
“there is little robust data available to guide the clinician with respect to the most appropriate drug to prescribe”

15. Rx of New Psychosis Long-term antipsychotics are effective
50-75% full or partial response
Return to premorbid function w. encapsulated belief
Compliance problematic - CPN
May require admission first
Side effects
Relieve isolation and deafness
Atypicals preferred, but lack of robust evidence

16. Side effects of Antipsychotics
EPSE
Parkinsonism
Akathesia
Orofacial dyskinesia
Tardive dyskinesia
Sedation
Postural Hypotension

17. Metabolic
Weight gain (30% gain >7% with olanzapine), Type II diabetes, lipids
Cognition
Increased rate of cognitive decline
Holmes et al 1997

18. Suggested drug dose Initial dose (mg) Max (mg)/day Risperidone 2
Olanzapine
2.5
10-15
Amisulpiride
25 bd
150
Quetiapine 25
80-160
Clozapine
6.25
50-100

19. Treatment LOS: non-pharmacological
Cognitive Behavioural Therapy
Cognitive Behaviour Social Skills Training
Functional Skills Training

20. Delirium

21. Delirium Common, preventable, treatable
Distressing pt, staff and family
Associated with a poor prognosis

22. Prevalence Community Prevalence by age, N=810 10-30% in hospital wards
Folstein et al,1991

23. Core Features Acute onset, fluctuant course
Variable attention / consciousness
Disturbance of cognition
Impaired immediate recall
Disorientation to TP
Disturbed behaviour and arousal
Irritable, restless, angry or disinhibited
Hypo-alert, psychomotor retardation

24. Disturbance of sleep-wake cycle, insomnia
Nocturnal worsening of symptoms
Abnormality of mood
Psychotic symptoms
Illusions
Visual hallucinations
Persecutory delusions -less complex
Misidentification/misinterpretation
Underlying cause

25. Aetiology Risk Factors Precipitating factors Sensory impairment
Cognitive impairment
25% delirious are demented
40% demented in hospital are delirious
Dehydration
Severe illness, hip fracture, alcoholism
Precipitating factors
Infection
Pain
Constipation
Drugs: opiates, benzo, anticholinergic
Poor nutrition
Catheterisation

26. Treatment Underlying cause Rx symptoms of delirium
Environmental
Pharmacological
Mean duration days, up to 6 weeks
Follow up: slight majority become demented in 2 years

27. Pharmacology 0.5mg Haloperidol 6pm and 10pm
Second line: 1mg lorazepam bd
Diazepam for alcohol withdrawal

28. Neurodegenerative

29. Case example of Alzheimer’s
Gradual progressive onset memory loss
Global deficits
Disorientated TPP
Language
Self care
Visuospatial
Affect, personality
Behavioural + Psychological Sx Dementia

30. Alzheimer’s Disease Prevalence of psychosis 30-50%
Delusions more common that hallucinations

31. Rx of psychosis in AD Antipsychotics Cholinesterase inhibitors
No RCT, but data suggests some value in reducing psychotic symptoms

32. Dementia with Lewy Body
Cognitive decline
Fluctuating cognitive performance
Parkinsonism 70%
Complex Visual Hall
Falls and syncopal episodes 30%
Neuoleptic sensitivity

33. Lewy Body Dementia Psychotic symptoms most common
Visual Hallucination (80%)
Delusions (65%)
Auditory Hallucinations (20%)
McKeith et al, 1996

34. Rx of psychotic sx DLB
Balance between anti-parkinsonian medication and psychotic symptoms

35. Rx psychotic sx DLB Antipsychotics Extreme sensitvity to neuroleptics
50% life threatening AE of Parkinsonism Sx
Dose related
No robust studies
Cholinesterase inhibitors
Large multi-centre DBRCT compared rivastigmine with placebo showed improvement in delusions and hallucinations
McKeith et al, 1992

36. Parkinson’s disease Psychotic sx most commonly iatrogenic 20-60%
Visual Hallucinations
Risk of PS greater in later stages of disease when concurrent dementia or depressive illness

37. Rx of psychotic sx in Parkinson’s disease
Review medication
Cholinesterase inhibitors

38. Affective
Depression
Mania

39. Core features Depressed mood, diurnal variation etc
Psychomotor retardation or agitation 30%
Degree of cognitive impairment in 70%
Delusions 45% of poverty, guilt, nihilism
Cotard’s syndrome

40. Rx of psychotic Sx in depression
Antidepressant and antipsychotic
Response as good as in the young
Higher risk of relapse and chronicity
ECT psychotic depression

41. Mania 2 peaks Vascular pathology underlies late onset
Clinically: rarely euphoric, more irritability, paranoia and mild confusion
More often followed by depression

42. Hallucinations of sensory deprivation
Charles Bonnet syndrome

43. Conclusions Psychotic symptoms occur in a range of conditions
They’re important cause of morbidity
There are effective treatments
Acute symptoms: search for physical cause of delirium
Chronic symptoms and distress: psych liaison. Sector referral for LT follow up