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 0-470-84641-090Clinical Assessment and Differential DiagnosisD. N. AndersonMossley Hill Hospital, Liverpool, UKThe schizophrenias of late life, previously called late paraphrenia 1and paranoid states in old age, present fascinating, complex,biopsychosocial problems that span the whole of psychiatry andmedicine. The characteristic features of late-onset schizophreniahave been summarized by several authors 2–10 , although neverbetter than in the seminal paper by Kay and Roth 2 .These conditions usually present with paranoid ideation, mostcommonly persecutory in nature, with or without other schizophrenia-likesymptoms. The central abnormality implied by theterm ‘‘paranoid’’ is a morbid distortion of beliefs, but not alldistorted beliefs are delusions and not all elderly people expressingthem are mentally ill. Many aspects of old age increasevulnerability, exposing elderly people to abuse and victimization,and a sensitive appreciation of this situation is needed whenassessing the paranoid elderly patient.Furthermore, not all patients with delusions have schizophrenia11 and the first aim of assessment will be to clarify the nature ofparanoid symptoms and consider a differential diagnosis. In mostcases a diagnosis will be clear from the detailed historical accountof symptoms and their course, abnormalities of mental state andsimple physical investigations. Assessment must, then, evaluatethe individual’s level of functioning, independence, vulnerability,social and family support and physical health, which will all be ofrelevance to aetiology and management. The assessment will aimto consider patients and their symptoms within the wider contextof their social environment, physical and psychological limitations.It is, therefore, necessary to have knowledge of premorbidpersonality, life style, life experience and cultural background,remembering that young and older generations have importantcultural differences.Ideally, the assessment will take place in the patient’s home,when environment may be maximally appreciated. Home assessmentprovides a more complete picture of the patient’scircumstances and helps put the problem into a living context.Commonly, paranoid ideas in old age relate to the patient’simmediate, local environment and people within it. Herbert andJacobson 3 used the term ‘‘partition delusions’’ to describe thebelief that things were happening just the other side of the wall,floor or ceiling. Post 12 found that paranoid symptoms oftentemporarily disappeared when the patient was removed from thehostile environment and this can give a misleading impression oftheir nature.The floridly deluded and hallucinated patient is easilyrecognized, but in old age paranoid ideation may be almostplausible when complaints of being abused, victimized, stolenfrom or manipulated are not beyond the bounds of possibility.Trying to establish the validity of such claims requires observationand information from a variety of sources.Table 90.1Differential diagnosisDeliriumDementiaOrganic delusional/hallucinatory disorder, secondary to physical illnessor drugsLate-onset schizophreniaDelusional disorderDepressionManiaSchizoaffective disorderParanoid personality disorderFactual (basis in fact)Sensory impairmentWe need, first, to consider the differential diagnosis of paranoidsymptoms (Table 90.1) and how clinical assessment helps todifferentiate diagnostic categories before discussing the process ofassessment in more detail.DIFFERENTIAL DIAGNOSISChristensen and Blazer 13 found the prevalence of paranoid ideasin a community sample to be 4%. Leuchter and Spar 14 retrospectivelyreviewed 880 psychogeriatric admissions and the 8%who suffered a first episode psychotic illness met DSM-III criteriafor major affective disorder (36%), organic mental disorder (43%)and primary paranoid disorder (21%). The more commonconditions will be reviewed briefly from the point of clinicaldifferentiation, although for detailed consideration referenceshould be made to the relevant chapters.Delirium (Acute Confusion)The history is short, usually days or a few weeks, and the onsetrapid. Paranoid ideas and hallucinations occur in 40–50% 15 .These are typically poorly organized, fluctuating and variable incontent, while hallucinations most commonly occur in the visualmodality. Other features of delirium will normally be present.Dementia (Chronic Confusion)Ballinger et al. 16 found delusions and hallucinations in 38% and34% of 100 dementia admissions. The study by Burns et al. 17 ofPrinciples 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