Bipolar,Schizo,Psychosis

Question 1

Differential diagnosis of older adult presenting with psychosis

Answer 1

1. Dementia/MCI
2. Psychotic depression
3. Bipolar disorder
4. Schizophrenia
5. Schizoaffective disorder
6. Delusional disorder
7. Isolated psychotic symptoms
8. Brief psychotic disorder
9. Secondary psychosis (stroke, tumor, med)
10. Charles Bonnet syndrome

Question 2

Recommendations for treatment of psychosis in older adults

Answer 2

Generally:
1. Atypical antipsychotics
2. Li or divalproex for BPD
3. Citalopram for AD
4. Rivastigmine or donepezil for PD
5. Donepezil for LBD

Question 3

Features specific to older age bipolar disorder

Answer 3

1. Severity of symptoms decrease over time
2. Severity of mood sx (mania and depression) less severe
3. Often have both mania and depression at the same time
4. Decreased risk of suicide
5. High rates of SUD but less than younger

Question 4

What is the age cut off for late onset bipolar disorder?

Answer 4

50+ years old

Question 5

What are features of late onset bipolar disorder?

Answer 5

More strongly associated with cerebrovascular disease
High risk of cognitive deterioration
Psychotic symptoms less frequent
Depressive symptoms more frequent

Question 6

What are imaging findings in bipolar disorder?

Answer 6

Reduction in regional grey matter volume, including frontal and subcortical
OABD = more pronounced volume loss in caudate
LOBD = decreased brain volume

Question 7

What are cognitive changes in person with older adult bipolar disorder?

Answer 7

Risk of dementia 2x higher
Most in attention and executive functioning
Immediate and working memory, processing speed
ACHEI may destabilize BD symptoms
Lithium may decrease risk of development into dementia

Question 8

Recommended treatment options for OABD

Answer 8

Manage vascular risk factors
Typically antipsychotic +/- mood stabilizer
1. Lithium - lots of drug interactions
2. Valproic acid - well tolerated, less protein binding, longer half life
3. Lamotrigine - well tolerated
4. Carbamazepine - CYP2D6 inducer
5. Antipsychotics - first line in a cute mania
6. Antidepressants

Question 9

What are the definitions of late onset and very late onset schizophrenia?

Answer 9

After 40 yo = late onset (1%)
After 60 yo = very late onset (0.3%)

Question 10

What are features of late onset schizophrenia?

Answer 10

F>M
Lower rate family hx
More preserved psychosocial functioning
Less positive symptoms
Better processing speed and abstraction

Question 11

What are features of very late onset schizophrenia?

Answer 11

High prevalence of partition delusions
Hallucinations multi sensory
Thought disorder less common
Negative symptoms less common
More combative and angry

Question 12

What cognitive changes are seen in schizophrenia?

Answer 12

Usually predate psychotic symptoms
1. Processing speed
2. Working and episodic memory
3. Difficulty learning new things
Many people develop dementia

Question 13

What are the management options for schizophrenia?

Answer 13

Antipsychotics first line
Clozapine best for treatment resistant
Use lower doses than younger patients
Risperidone 1.25-3.5 mg/d
Quetiapine 100-300 mg/d
Olanzapine 7.5-15 mg/d
Psychosocial - CBT social skills, supported employment, functional adaptation skills training