Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-095Treatment of Late-onset Psychotic DisordersElsa M. Zayas and George T. GrossbergSt Louis University, St Louis, MO, USAAs the world population ages, a greater proportion of thepopulation will be over the age of 65. Psychopathology canpresent in various ways in the elderly. Psychoses, as defined inDSM-IV, consist of ‘‘delusions or prominent hallucinationsoccurring in the absence of insight into their pathologicalnature’’ 1 . Hallucinations can be visual, auditory, tactile and/orolfactory in nature. Delusions or falsely-held beliefs are at timesvery difficult to distinguish from reality. They may requirecorroboration from caregivers to authenticate their psychoticnature.Psychotic disorders can present in the elderly as either chronicor acute conditions. The disorders can include early- and lateonsetschizophrenia, schizoaffective disorders, delusional disorder,mood disorders with psychotic symptoms, delirium and dementiaswith psychosis. Furthermore, the etiology of psychosis can be theresult of medical conditions, such as Parkinson’s disease orneoplasms, as well as drugs or other substances (Table 95.1).Table 95.1Psychotic disorders manifested in the elderlySchizophreniaLate-onsetAging patients with early onsetSchizoaffective disorderPsychosis NOSDelusional disorderDementia with psychotic symptomsAlzheimer’s dementiaVascular dementiaLewy body dementiaMixed dementiasDeliriumPsychoses due to a general medical conditionPsychoses due to a substanceMood disorders with psychotic symptomsEPIDEMIOLOGYThe geriatric data from the Epidemiologic Catchment Area studyshowed, at three sites, a 6 month prevalence for schizophrenia andschizophreniform disorders of 0.2–0.9%; cognitive impairment,including organic psychosis, was 16.8–23% 2 . Reported prevalencesof psychotic disorders in a nursing home population was10% and in a community-based sample in Sweden 4.7% 3,4 .Patients with Alzheimer’s disease may also exhibit psychoticsymptoms, with reported prevalences as high as 63% 5 .Patients with late-onset schizophrenia (LOS) present with theirpsychotic symptoms after the age of 45. LOS tend to bepredominantly women, and have better premorbid functioningcompared to younger schizophrenics 6 . Women with late-onsetcompared to early-onset schizophrenia tend to have more severepositive symptoms and fewer negative symptoms when comparedto men with late onset of the disorder 7 . Women also tend to haveless social withdrawal, better premorbid functioning and agradual decline in functioning 8,9 . Patients with late-onset schizophreniatend to have less affect flattening and formal thoughtdisorder 6 . Aging patients who suffer from schizophrenia may haveless intensity of their symptoms 10 .Delusional disorders are defined as non-bizarre falsely-heldbeliefs with minimal hallucinations 1 . Delusional disorders oftenhave their onset in mid- or late life 11 and tend to affect men earlierthan women 12 . Low socioeconomic status, immigration, hearingloss and bedfast status are some of the risk factors for developinga delusional disorder 13–16 . Psychotic symptoms seen in dementiascan consist of hallucinations or delusions.NEUROCHEMICAL HYPOTHESISThe dopamine hypothesis of schizophrenia associates an increasein the activity of dopamine in various cortical areas that areconcerned with positive, negative and cognitive symptoms ofschizophrenia, as well as side effects seen with the use ofneuroleptics. An increase in the level of dopamine activity in themesolimbic pathways of the brain would be associated with thepsychotic symptoms seen, i.e. hallucinations and delusions.Blockade in activity at the mesocortical pathway would beassociated with cognitive symptoms and may account forworsening of the negative symptoms seen with conventionalantipsychotics. Blockade of dopamine at the tubuloinfundibulartract is associated with increases in prolactin levels, a troublesomeside effect which, in younger patients, may lead to non-complianceand discontinuation of treatment.DIFFERENTIAL DIAGNOSISPrior to initiating treatment, it is essential to conduct abiopsychosocial evaluation of the patient. Delirium is often thecause of an acute onset of psychotic symptoms in the elderly andmust be foremost in one’s differential assessment. Delirium,defined as an acute mental status change with waxing and waningof the levels of consciousness, often presents with hallucinations,predominantly visual, as well as delusions.Medical conditions in the elderly that can cause deliriuminclude: infection (frequently urinary tract infections); metabolicdisorders (thyroid disease, diabetes); electrolyte imbalances; pain;Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd