Download Psychosis in the Older Patient

Psychosis in the Older
Patient
Module 1
Thomas Magnuson, M.D.
Assistant Professor
Division of Geriatric Psychiatry
Department of Psychiatry
UNMC
PROCESS
A series of modules and questions
Step #1: Power point module with voice
overlay
Step #2: Case-based question and answer
Step # 3: Proceed to additional modules or
take a break
Overall Objectives
Upon completion the learner will be able to:
Define psychosis
Delineate common etiologies for
psychosis in older patients
Describe common treatment modalities for
psychosis in geriatric patients
Case
78 year-old white male
Alzheimer’s Disease for three years
-MMSE=14
Striking out at visual hallucinations
-two week onset
-daily, mainly after dinner
-lasts 3-4 hours
Case
Recent move into the NH from home
Traumatic for his wife
Medications
Atrovent, Glucatrol XL, Tylenol. Metoprolol, Aricept
Recent use of PRN Haldol 5mg IM
Nearly knocked over a peer
Medical workup
Vital signs stable
CBC,BMP, TSH, B12, UA, glucose all normal
Pulse oxygen>91%
Case
Mood unremarkable
No pain issues or falls
No cataracts, macular degeneration or
glaucoma
No history of severe mental illness or past
psychotic episodes
No alcohol history
No head trauma history
Psychosis
What is psychosis?
Hallucinations
• A perception without a stimuli
• Can occur in any sensory modality
Delusions
• A fixed, false belief
• Paranoid, persecutory, grandiose, somatic, erotomanic, and
jealous types
Disorganized speech
Disorganized behavior
Psychotic disorders
Schizophrenia
Schizoaffective disorder
Delusional disorder
Mood disorders with psychosis
Dementia
Delirium
Due to medications, substances
Due to a medical condition
Psychosis in the Elderly
About 25% of older adults will experience
psychotic symptoms
Onset
Pre-senile
• Before age 65
• Long-standing mental illness
Senile
• After age 65
• Dementia- and mood-related
Schizophrenia
Onset usually of long standing
Men 18-22; Women 22-26
Symptoms
Two of the following positive symptoms
• Hallucinations (auditory), delusions, disorganized thoughts,
disorganized actions
• Or conversation between voices alone
Negative symptoms
• Anhedonia, alexithymia, avolitional
Present for 6 months
Schizophrenia
Long past psychiatric histories
Many medications
• Extrapyramidal symptoms (EPS), esp. tardive dyskinesia
Multiple hospitalizations
Periods of legal commitment
Socio-economic status
Years on disability
Little family involvement
Legal guardian
Schizophrenia
Late-onset
More common in women
Less severe, less common
Negative symptoms more common
Hallucinations in all modalities
Paranoid, persecutory delusions
Less likely to have a family history
More likely married
Reclusive, suspicious by nature premorbidly
Schizophrenia in the Elderly
More older people living with schizophrenia
Improved treatment options
• Safer and limit poor outcomes
No warehousing
• Less risk of communicable disease
Improved community resources
• Fewer street people living dangerously
Living in nursing homes, assisted living facilities,
group homes, boarding houses and with family
• Tend to be easier to control with age
Schizoaffective Disorder
Variant of Schizophrenia
Psychotic symptoms and mood symptoms
together
• Psychotic symptoms occur alone; mood symptoms
generally do not
• Flip side of depression with psychosis
Unknown number of geriatric patients
• Usually adult-onset
Treat both psychosis and mood
Delusional disorder
Presence of at least one month of persistent
delusions
Paranoid, somatic, erotomanic, jealous, grandiose,
mixed
Presents in mid-to late adulthood
Age of onset for men (40s) earlier than women (60s)
Prevalence
0.03%
Lifetime risk is 0.05-0.1%
Delusional Disorder
Non-bizarre delusions
Everyday life situations
Risks:
• Sensory deficits
 Poor hearing/paranoia link not clear
• Immigrants, poor people
• Schizoid, avoidant, paranoid personality disorders
Mood Disorder with Psychosis
Depression or mania
Psychosis more prevalent in elderly depressed
patients
Late onset depression more common than late
onset bipolar disorder
Psychosis more common in late onset depression
Treatment entails treating both the depression and
the psychosis
The End of Module One
on
Psychosis in the Older
Patient
Post test question 1
Which of the following is the most likely long-term
outcome with aging in patients with early-onset
schizophrenia?
A. Gradual regression and functional decline
B. Remission of symptoms
C. Increased risk for Parkinson’s disease
D. Accelerated onset of dementia of the Alzheimer’s
type
E. Development of frontal lobe dementia
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.
Answer: B. Remission of symptoms
According to recent research, most patients with
early-onset schizophrenia have partial to full
remission by old age. Dosages of antipsychotic in
these patients should be monitored and decreased
as symptoms remit.
In patients who have not been institutionalized for
long periods of time, deterioration in function
because of schizophrenia itself is a less common
outcome.
Although parkinsonian symptoms can be
associated with the use of antipsychotics in high
doses, the risk for developing Parkinson’s disease
is not increased in patients with schizophrenia.
Early-onset schizophrenia is not associated with
an increased risk for developing dementia of the
Alzheimer’s type. A significant minority of
patients with schizophrenia develop frontal lobe
dementia, but this is not the most likely long-term
outcome for these patients. Go to next question
post-test question 2
A 75-year-old woman is in good general health and has been
living alone since her husband’s death 1 year ago. Her son,
who visits daily, notices that she now is less attentive to
household chores and continues to wear the same clothes
until he prompts her to change. She often eats cold cereal
instead of preparing hot meals. In the past 3 months, she
has told him that her money is not safe and that someone is
taking blank checks out of her purse. She claims that “the
mailman might not be who he says he is” and fears that her
mail is being stolen. She also begins to criticize her son for
not coming to see her, despite his daily visits. Risperidone,
0.25 mg orally daily at bedtime, is begun. The patient
subsequently complains less about theft but remains
unkempt and disorganized. Which of the following is the
most likely diagnosis?
Which of the following is the most
likely diagnosis?
A.
B.
C.
D.
Complicated bereavement
Late-onset schizophrenia
Major depressive disorder with delusions
Dementia of the Alzheimer’s type with
delusions
Answer: D. Dementia of the Alzheimer’s type
with delusions
Delusions and misperceptions occur frequently in
dementia and may occur very early in the course
of cognitive decline. The delusions often are
persecutory in nature, such as fears of theft,
spousal infidelity, and poisoning or malevolent
intent by others. They often involve family
members or others who are close to the patient.
Treatment with antipsychotic medications such as
risperidone may be beneficial, but the underlying
dementia also should be evaluated and treated.
Cholinesterase inhibitors have been shown to
improve cognitive function in early Alzheimer’s
disease.
Complicated bereavement is a substantial problem after spousal loss in
late life. Symptoms of depression often persist for up to 1 year.
Complications include increased medical complaints, substance abuse,
anxiety, sleeplessness, and protracted depressive symptoms that may
exceed 1 year. Delusions typically do not occur. Schizophrenia
typically begins in late adolescence or early adulthood, so illness
occurring after age 45 is considered late-onset; new onset at age 75
would be unusual. Delusions associated with schizophrenia may be
persecutory but commonly are bizarre (eg, aliens placing computer
chips in one’s head). Auditory hallucinations also may occur. In
dementia, visual hallucinations (eg, seeing people entering one’s home
at night) are more common. Major depressive disorder may occur in
late life and may be associated with delusions. However, the typical
presentation is characterized by sleep disturbance, increased somatic
complaints, weight loss, feelings of guilt and self-deprecation,
tearfulness, and hopelessness. When delusions occur, they often are
associated with themes of guilt or worthlessness, such as a belief that
one deserves incarceration for some trivial offense that occurred
decades ago.
end