Transcript Psychotic Disorders of Old Age

Psychotic Disorders in Older
People
• Judy Rubinsztein
• Consultant Psychiatrist for Older People
• MBChB, MRCPsych,PhD (Cantab)
Scope of Talk on Psychosis in
Elderly
• Definition of Psychosis
• Types of Psychotic Ilnesses in Older
People:
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Delusional Disorder
Schizophrenia (in Older People)
Mood Disorders
Psychosis in Dementia
Delirium (not covered)
Some Definitions
• Psychosis
• Delusion
• Hallucination (visual, auditory, olfactory,
tactile, gustatory or of deep sensations)
Psychosis
Psychosis: “out of touch with reality”
Delusion
A false unshakeable belief not in keeping
with a person’s educational and cultural
background
Hallucinations
A percept experienced in the absence of an
external stimulus to the sense organs.
Originates in the outside world.
Diagnosis
Case History 1
• 67 year old lady (ex general nurse), single , lives alone,
no children
• Intruders are coming in to the house every night, eating
from fridge, moving things around.
• She has baseball bat near front door.
• Complaining to police for over a year
History continued-1
• Memory and cognition appear grossly
intact
• No hallucinations
• Not overtly depressed or manic
• No past psychiatric history.
• Type II diabetic, bit of angina
• Not self- neglecting, coping with house
work, eating, socialising reasonably
Differential diagnosis?
Differential diagnosis for Paranoid
Psychoses
• Delusional Disorder ( ICD10):
- permanent and unshakeable delusional system,
- developing in middle or late life.
- Delusional system is encapsulated.
- Able to function e.g. Doing housework
- (Exclude if pt has persistent auditory
hallucinations, occ ok)
Differential Diagnosis
• Delusional disorder
• (Late) Schizophrenia
• Dementia
• Affective disorder
Late Schizophrenia
Bleuler ( 1943) defined as:
• Onset over 40
• Symptomotology the same as in SZ in
early life
• Not possible to attribute to
neuropathological disorder because of an
amnestic syndrome/ associated signs of
organic brain disease
Onset over 60
• 15-17% over 40 (Bleuler)
• But only 4% over 60yrs ( Bleuler)
Sensory Defects
• 30-40% of paranoid psychotics have
impaired hearing
• Visual impairment commoner inIn elderly
with “paranoid psychoses”
Terminology
• Term late paraphrenia in ICD9, did not
survive into ICD10
• Delusional Disorder suggested instead of
this term in ICD 10 (occasional or
transitory auditory hallucinations allowed)
• If clear and persistent auditory
hallucinations present- call it SZ
• Future: onset 40-59: late onset SZ
• Over 60: very late onset SZ
Personality in paranoid psychoses
of later life
• Often withdrawn, suspicious, sensitive
premorbid personality- paranoid/ schizoid
type
• Occ schizophreniform illness earlier in life
• Often unmarried, or if married childless
• Cold, unloving parents
• Live in self created isolation
Environmental
• Occasional life events, paranoid reactions
in sensitive personalities
Genetics
• Increased risk of schizophrenia in relative
of an affected proband is 10% compared
with risk of 1% in general population
• This does not seem to hold for late onset
SZ: ( Howard et al. 1997), rates 2.2% in
controls and 2.3% in relatives of cases
Sex ratio
• Female preponderance in middle and old
age SZ
Prognosis
• Treatment leads to a less florid illness
• Prognosis better if shorter, good initial
response
• Prognosis is worse: if severe personality
difficulties, deafness, cerebrovascular
disease, non compliance with medication
• Higher rates of conversion to dementia
Treatment
• Establishing a therapeutic relationship
• Hospital admission if necessary
• Neuroleptics needed, depot may be
useful- no PCTs, response is modest
• Social assessment and therapy
Case 2
• 84 year old man, widowed, helps to care
for brother with dementia, live together
• Ideas of ruin (became fixed after 3 weeks
in hospital), no solutions to any of social
problems – unable to care for brother, no
money to set up home- (untrue), hopeless
and suicidal
• No past psychiatric history
Diagnosis?
Diagnosis
• Depressive disorder with psychosisnihilistic delusions
• Prominent suicidal ideas
• Consider dementia
Treatment
• Admission as suicidal with close
observations.
• Treatment with antidepressants and
antipsychotics
• ECT may be indicated
• Carer burden too great- arrangement
placement for relative
• Consider future care needs of patient
Case History 3
68 year old man spying on neighbours, cut
hole in hedge to watch them, not sleeping,
overly energetic. Abusive to neighbour.
Arrested. Forensic Liaison nurse arranges
psychiatric assessment. Not known to
psychiatric services
Differential Diagnosis
Bipolar Disorder in Elderly
• Rare to present over 65, most have a
history
• Need to re-examine past psychiatric
history
• Consider organic causes
Unipolar Mania (Prevalence)
• 0.1% in over 64s
• Inpatient OA units ( 4-8%) of bipolar
patients
• Peaks of onset at 37 and 73
Unipolar Mania: Aetiology
Always consider if there a relationship with
physical illness
e.g. Stroke, Infection,Tumour
• So always do a brain scan
Unipolar Mania: Clinical Features
• Presentation of mania may be modified in
elderly (how?)
• Can be mistaken for delirium
• Concerns that there is more cognitive
dysfunction in late onset mania
Secondary Mania/ Disinhibition
Syndrome
• Right sided lesions for mania and
pseudomania confirmed as trend ( Braun,
1999)
• Vascular lesions (strokes)
• Head injuries/ tumours
• Endocrine conditions
• HIV
• Epilepsy
Treatment
• Hospital admission may be indicated
• Full assessment of social factors, isolation,
housing, family support
• Drug Treatment: atypical antipsychotics at
lower doses. Consider lithium, some
consider valproate/lamotrigine.
• If very severe and life threatening,
consider ECT
Treatment: pitfalls/ problems
• Antipsychotics cause sedation in an
overactive patient, this together with EPSE
may lead to falls.
• Follow-up is needed.
• Consider long term prophylaxis with
lithium, adherence can be a problem.
Clinical course and outcome
• Long latency between first episode of
depression and mania ( 15 years) in those
that start with depressive episodes
( Shulman and Post, 1980)
• Less likely to respond to treatment and
have higher prevalence of CVS disease
adn cognitive dysfunction(Berrios and
Bakshi).
• Higher mortality and morbidity in late onset
manic patients
Case history 4
• 78 year old widower, lives alone.
• GP called out urgently as Mr S is very scared
there are rats in the house (seeing them),
petrified and screaming.
History -4 cont
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Tremor in hands noted
No past psychiatric history
No history of alcohol abuse
No current or recent medical problems
(no UTI, chest infection)
• Mild cognitive problems
Differential Diagnosis
Differential diagnosis
• Dementia with visual hallucinations: LBD,
Vascular dementia, AD
• Alcohol withdrawal
• Delirium
Treatment
• Hospitalisation/ Crisis team management
• Caution with neuroleptics
Consider Rivastigmine/ Aricept
Underlying physical problems contributing
Take Home Message
• Psychosis = out of touch with reality
• Wide differential in older people:
Take Home Messages
• Late onset schizophrenia
• Delusional disorder (specific to later life,
symptoms may be circumscribed,
personality intact)
• Dementia: always consider in older
people/ organic component may become
more evident
• Consider delirium
• Mania rare
Take Home Messages
• Psychosis= out of touch with reality
• Common psychoses in elderly:
-Late onset schizophrenia
-Delusional disorder
-Mood disorder
-Dementia
-Delirium
MCQs
• African and Caribbean –born elders in the
UK are at higher risk of developing
psychosis
• In late paraphrenia visual impairment is
higher than in controls
• Silent cerebral infarcts are present in over
20% of patients with late onset mania