Old age psychosis

Question 1

Differential for psychosis in the elderly

Answer 1

Delirium, Alzheimer’s psychosis, Lewy Body Dementia (LBD), Psychotic depression, Alcoholic Hallucinosis -

Question 2

Acute Delirium

Answer 2

Secondary to infection and fluctuating mental state

poorly formed delusions with visual and auditory hallucinations

Question 3

Alzheimer’s psychosis

Answer 3

Onset after onset of dementia, delusions>hallucinations, interfere with functioning and lasting over a month
Delusions are mainly persecutory (theft, infidelity, abandonment)
Misidentification phenomena - Mirror sign, TV sign, Phantom Boarder

Question 4

Lewy Body Dementia (LBD)

Answer 4

20% of dementia - Recurrent, well formed and detailed visual hallucinations are key
Background of fluctuating mental state, falls +- parkinsonism

Question 5

Psychotic depression

Answer 5

2% prevalence - but can be up to 35% of older inpatients. Delusions - persecutory, hypochondriacal, poverty. Hallucinations - 2 person auditory, somatic, olfactory, gustatory. 20% show first rank symptoms - strong link to physical co-morbidity in older patients

Question 6

Alcoholic Hallucinosis

Answer 6

2nd person auditory hallucinations most commonly + persecutory delusions/delusions of reference
Co-morbid depression and cognitive impairment
Requires a history of excessive alcohol intake

Question 7

Incidence of Schizophrenia by age

Answer 7

Major spike in males at 18-25 and a second increase after 70

In women there is flatter incidence up to 70 and higher risk after - Women at greater risk from 40yrs>

Question 8

Late onset schizophrenia (LOS)

Answer 8

Onset after 40yrs - incidence 12.6/100,000

Question 9

Very-late-onset schizophrenia-like psychosis (SLP)

Answer 9

Onset after 60yrs - incidence 17-24/100,000

No primary affective disorder, MMSE >24/30, No neurological illness, excessive alcohol intake or other cause

Question 10

Difference between early and late schizophrenia

Answer 10

Late has all schiz symptoms except Formal thought disorder or Negative symptoms
Additionally have complex visual hallucinations and partition delusions

Question 11

Partition Delusions

Answer 11

The delusional belief that objects or people are able to pass or see through walls or partitions.
Watched/overheard through wall - 40%, Intruder or theft in home 34%, Non-person intrusion - 30%, Somatic impact of intrusion - 20%

Question 12

Hallucinations in SLP

Answer 12

Non-verbal auditory - 70%
3rd person auditory - 50%
Other modalities - 30%

Question 13

Delusions in SLP

Answer 13

Persecutory - 85%
Reference 75%
Partition 70%
Misidentification 60%

Question 14

Brain imaging in SLP

Answer 14

Similar to normal schiz - increased ventricular volume and frontal + temporal grey matter loss
No evidence of increased small vessel disease

Question 15

SLP and cognitive decline

Answer 15

25% of SLP patients have a cognitive impairment consistent with a diagnosis of dementia within 3yrs. 75% has a stable cognitive deficit
Has been argued that SLP is a neurodengenerative type of schizophrenia

Question 16

Risk Factors for SLP

Answer 16

women have a 4x risk - poss loss of protective estrogen effect. Incidence increases by 11% for every 5yrs above 60yrs. Sensory deficits - 40% have auditory and 20% visual. Pre-morbid personality - paranoid/depressive/anxious/schizoid - Unmarried & socially isolated

Question 17

Migration and SLP

Answer 17

Earlier mean onset age of SLP and less female preponderance

Question 18

Treatment of SLP

Answer 18

Observational studies indicate that low dose(10-25%) antipsychotic medication is effective
Additionally engagement with keyworker and increased positive social interactions can improve outcomes

Question 19

Pharmacokinetics of older people

Answer 19

Increased gastric absorption and decreased motility. Decreased 1st pass hepatic metabolism. Increased volume of distribution due to decreased protein binding and increased fat. Decreased liver and renal clearance

Question 20

Commonly used antipsychotics to treat SLP

Answer 20

Risperidone, Quetiapine, Amisulprine, Olanzapeine - atypicals are better - pyrimidal side effects are warning signs of CVA (particularly risperidone and olanzapine)