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Psychosis in the Older
Patient
Module 2
Thomas Magnuson, M.D.
Assistant Professor
Division of Geriatric Psychiatry
Department of Psychiatry
UNMC
Updated 1/25/06
Objectives
Upon completion the learner will be able to:
List the common etiologies for psychosis
in the elderly
Describe the common presentations of
these etiologies
Dementia
50% of all demented patients will have psychosis
30% have paranoid delusions
• Concrete, interpersonal
 Specific people stealing, spying
 “Capgras-like” delusions
20-50% hallucinations
• Visual slightly more than auditory
• Women more than men
• NH, hospital more than the community
Dementia
Present in all forms of dementia
Certain considerations for some dementias
• Lewy Body Dementia
 Cortical and subcortical features
 Parkinsonian-like presentation
 Fluctuating course
 Vivid visual hallucinations
 Using antipsychotics worsens their symptoms
 Even newer, atypical agents
 May even increase mortality rate
Dementia
Parkinson’s dementia
Common outcome
Occurs late in the process
Medication-derived
Using traditional and some atypical
antipsychotics worsens their movement
• Clozapine and Seroquel less likely to add to
movement problems
Delirium
Transient, global reversible cerebral dysfunction
Acute in onset
Fluctuating course
Inattention
13-27% of hospital patients
Psychosis usually present
• Delusions
• Visual and tactile hallucinations
Delirium
Age over 60 is a risk factor
28-44% after hip fracture
38% admitted to a general hospital
Increased risk with preexisting cognitive
impairment and degree of medical morbidity
Etiologies
Medications (48%)
Metabolic disorders (30%)
Neurological disorders (20%)
Infections (17%), Hypoxia (14%)
Delirium
Older patients ……..medical conditions
Younger patients ….alcohol intoxication or
withdrawal
Higher rates of mortality than non-delirious
patients
More likely to develop dementia
More likely to lose independence
Delirium
Multiple etiologies
Drug intoxication and withdrawal,
metabolic problems, CV disorders, CNS
disorders, infections, post-op, sleep
deprivation
most likely multifactoral
Only 36% have one etiology
Delirium
Among previously community-dwelling
elderly
Delirium led to prolonged hospital stays
Increased risk of institutional placement
• Only 4% had complete resolution during the stay
Not as acute or reversible as once thought
• Chronic delirium can occur
• Herald sign in some who will develop dementia
Substance-induced Psychotic
Disorder
Iatrogenic
Common therapeutic agents
• Amphetamines
 Ritalin (methylphenidate), dexedrine
• Anticholinergics
 Benedryl (diphenhydramine), Cogentin (benztropine), many
antihistamines
• Benzodiazepines
• Tagamet (cimetidine)
• Cortisone
 “steroid psychosis”
Substance-induced Psychotic
Disorder
Iatrogenic agents
L-dopa/carbidopa and dopamine agonists
• Induced psychosis in Parkinson’s disease
Tertiary amine tricyclic antidepressants
• Amitriptyline, imipramine, clomipramine
Methytestosterone
Pentazocin
Phenylpropanolamine
Substance-induced Psychotic
Disorder
Recreational agents
Alcohol
• By far the most employed in this cohort
 Acute
 Chronic
Also
•
•
•
•
Cocaine
Marijuana
Methamphetamine
Narcotics
Psychotic Disorder due to a
General Medical Condition
Multiplicity of causes
Neurologic
• Degenerative
 Parkinson’s disease
• Trauma
 MVA
• Tumor
 Especially of the limbic system
• Vascular
 Stroke
Psychotic Disorder due to a
General Medical Condition
Metabolic
Folate deficiency
Hemodialysis
Hepatic encephalopathy
Hypocalcemia
Hypo- and hyperthyroidism
Hypoglycemia
Hyponatremia
Malnutrition
Pancreatic encephalopathy
Psychotic Disorder due to a
General Medical Condition
Metabolic
Parathyroidism
Pernicious anemia
SLE
Thiamine deficiency
Uremia
B-12 deficiency
Wilson’s disease
The End of Module Two
on
Psychosis in the Older
Patient
Post test question 1
A 70-year-old woman is brought by her husband for an
outpatient evaluation. She has a 3-week history of
hypersomnia, fatigue, and decreased attention span with
intermittent episodes of confusion. She states that she felt
“bugs crawling on her skin.” She has been taking
thioridazine 300 mg daily at bedtime for chronic paranoid
schizophrenia for several decades. Her chronic symptoms
of auditory hallucinations are well controlled. Fluoxetine
20 mg daily was initiated 1 month ago because of
complaints of poor motivation and low mood.
What is the most likely explanation for her current
condition?
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
What is the most likely explanation
for her current condition?
A. Acute exacerbation of schizophrenia with tactile
hallucinations
B. Neuroleptic malignant syndrome induced by
thioridazine
C. Progression of schizophrenia with increased
negative symptoms and early dementia
D. Major depressive disorder with psychotic
symptoms refractory to fluoxetine
E. Subacute delirium due to elevated thioridazine
levels
Answer: E. Subacute delirium due to elevated
thioridazine levels
The clinical scenario most likely reflects a subacute delirium.
The most common cause of subacute delirium in elderly
persons is multiple medications. When a previously stable
patient reports a new onset of confusion, it is essential to
ascertain whether any new medications or dosage increases
have been implemented. A medical evaluation should also
be pursued in this setting and include measurement of
electrolyte levels (hyponatremia may occur with
psychotropic agents), thyroid studies, general chemistry
profile, complete blood cell count, and, if clinically
indicated, electrocardiogram and computed tomography
scan of the head.
The clinical picture does not appear consistent with an exacerbation of
psychosis, as the patient’s chronic hallucinations were well under
control, and the new occurrence of tactile hallucinations is more
suggestive of delirium than schizophrenia. The clinical picture is also
inconsistent with neuroleptic malignant syndrome, which is
characterized by rigidity, fever, autonomic instability, mental status
change, and an elevated creatine kinase level. Neuroleptic malignant
syndrome typically occurs shortly after the introduction of an
antipsychotic medication for the first time. This clinical scenario is
also distinct from negative symptoms of schizophrenia that include
alogia (poverty of speech), avolition (absence of purposeful activity),
and affective flattening. Negative symptoms tend to be longstanding
difficulties that are not likely to present acutely or change in late life. It
is possible that the patient has an underlying insidious dementia
syndrome, but this is not likely to be the source of the current
symptoms. Her symptoms of confusion and tactile hallucinations are
more characteristic of delirium than depression.
The addition of a selective serotonin-reuptake inhibitor
(eg, fluoxetine, paroxetine) may elevate the levels of other
medications such as thioridazine through hepatic P-450
2D6 enzyme inhibition. Therefore, the addition of
fluoxetine may serve to elevate levels of tricyclic
antidepressants, morphine derivatives, phenothiazines, ßblockers, some antihypertensives (eg, captopril), and some
antiarrhythmic drugs (eg, quinidine). With the patient in
question, who was taking thioridazine 300 mg daily, the
addition of fluoxetine resulted in increased anticholinergic
effects, contributing to sedation and confusion. Because of
age-related decreases in hepatic function and vulnerability
to cognitive impairment with anticholinergic effects, older
persons are particularly susceptible to adverse effects from
drug-drug interactions. Elevated levels of thioridazine may
also be hazardous in that thioridazine can cause
prolongation of QTc intervals. Go to next question.
Post-test question 2
A 79-year-old man accompanied by his wife presents for evaluation.
She has brought him to medical attention because of her concern about
his delusional ideas. She reports that for the past year her husband has
believed that people were breaking into their home to steal from them.
He also believed that she had become unfaithful, and he confronted her
about “running off” with men each week when she went shopping for
groceries. The wife further reports that he has had increasing difficulty
with memory impairment over the past 5 years such that she has
assumed all household responsibilities, including the driving and
financial duties.
On examination the patient is noted to be alert and cooperative with a
full affect. His Mini–Mental State Examination score is 21/30. He has
a history of benign prostatic hyperplasia but no other medical illnesses.
His electrocardiogram reveals a left bundle branch block. Findings on
general chemistry profile and urinalysis are normal.
What is the most likely diagnosis?
What is the most likely diagnosis?
A. Late-onset schizophrenia
B. Delusional disorder
C. Dementia with superimposed delirium
D. Major depressive disorder with psychotic
features
E. Dementia with psychotic features
Answer: E. Dementia with
psychotic features
The patient in question has dementia with psychotic
features. His persecutory delusions involving
stolen belongings and spousal infidelity are two
common themes associated with the psychosis of
dementia. Delusions of this type may be
contrasted to delusions of schizophrenia, which
are more likely to be implausible and bizarre (eg,
the belief that aliens have implanted computer
chips in one’s head).
Late-onset schizophrenia (ie, onset after the age of 45 years) occurs in
a subset of patients with schizophrenia and has several characteristic
features. These features include a higher frequency among women, an
association with nonspecific central nervous system injury (eg,
periventricular hyperintensities seen on magnetic resonance imaging),
a premorbid history of schizotypal personality, and an increased
incidence of a family history of schizophrenia. Late-onset
schizophrenia is not typically associated with overt cognitive
deterioration. Delusional disorder is an uncommon condition,
occurring in 0.01% of the population, most often seen in men over the
age of 50 years, and characterized by discrete, plausible delusional
ideas in the absence of memory impairment or other psychotic
symptoms. Like late-onset schizophrenia, delusional disorder is not
associated with memory impairment. Delirium and depression are
other clinical conditions that must be excluded in this diagnosis. The
chronicity of the patient’s condition speaks against delirium, and the
absence of prominent mood symptoms makes depression an unlikely
diagnosis.
END.