The Older Patient
with Psychotic Symptoms
David Mamo
Consultant Psychiatrist, MCH, Malta
Clinical Lead, Geriatric Psychiatry, MCH, Malta
Associate Professor, Faculties of Medicine and Health Sc, UoM
Associate Professor of Psychiatry, University of Toronto
Learning Objectives
•
Be familiar with the common causes of psychosis in the elderly
•
Understand the importance of Secondary vs. Primary
Psychotic Disorders in the Elderly
•
Build confidence in the systematic triage including physical and
mental state examination, and initial management of a an older
person presenting with psychotic symptoms
•
Appreciate that aging is best considered as a dynamic course
than as a cross-sectional state, making psychosis in the elderly
“a moving target”.
•
Introduce the new and evolving geriatric mental health
services being developed in Malta
What is Psychosis?
Generally defined as “Hallucinations and
Delusions”
..but, often accompanied by
(a) Disorganized Thinking, and
(b) Disorganized Behavior
Hallucinations and Delusions
≠
Schizophrenia
Can be “PRIMARY” or “SECONDARY”
THERE ARE NO RELIABLE PATHOGNOMONIC
SIGNS TO DISTINGUISH PRIMARY Vs.
SECONDARY
Therefore, one must
(but especially in
the ELDERLY) consider and rule out secondary
causes.
Primary & Secondary Psychosis
Primary Psychotic Disorders
(a) Schizophrenia and Related Disorders
(b) Affective Psychosis
Secondary Psychotic Disorders
(a) Dementia: Alzheimer’s, Vascular, LBD, other
dementias
(b) Delirium: (I WATCH DEATH in PAIN)
(c) Substance-Induced (including medication!)
(d) General Medical Conditions (MINES)
Etiologies of Pychosis in Older Adults
(in order of frequency)
1. Alzheimer’s & other dementias
2. Depression
3. Medical / Toxin / Substance-Induced
4. Delirium
5. Bipolar Disorder
6. Delusional Disorder
7. Schizophrenia
8. Schizoaffective Disorder
Differential Diagnosis of the Older Patient with Psychotic Symptoms. Manepalli et
al; Primary Psychiatry, 2007.
Etiologies of Pychosis in Older Adults
(in order of frequency)
1. Alzheimer’s & other dementias
2. Depression
3. Medical / Toxin / Substance-Induced
4. Delirium
5. Bipolar Disorder
6. Delusional Disorder
7. Schizophrenia
8. Schizoaffective Disorder
Differential Diagnosis of the Older Patient with Psychotic Symptoms. Manepalli et
al; Primary Psychiatry, 2007.
Psychosis: A Common Clinical
Presentation in the Elderly
Community: 1-4%
Acute Psychogeriatric Hospital/Ward: 10%
Nursing Homes: up to 60%
Elderly without dementia > 85 years: 10%
VERY HIGH PREVALANCE OF ANTIPSYCHOTIC USE IN
NURSING HOMES Chen et al, Arch Internal Med, 2010
Psychosis: Risk Factors in the Elderly
1.
2.
3.
4.
5.
Sensory Deficits
Social Isolation
Cognitive Decline
Medical Comorbidities
Polypharmacy
Case 1: Psychosis – The Great Chameleon
Case 1: As your community’s psychogeriatric resource nurse, you
are asked to call on Mrs. Borg, a 92 year old widowed lady with no
past medical or psychiatric history living on her own with some
support from a home help worker 1 hour per day. You are told that
she has been acting strangely over the past few months, talking of
little people visiting her at night and observing unusual images on
her walls. You are told that her memory has declined over the past
few months and needs support in most iADL’s but is independent
of ADL’s. At this time your primary/working diagnosis is:
A. Late-Onset Schizophrenia
B. Psychosis Secondary to a Medical Illness
C. Dementia
D. Depression with Psychotic Symptoms
E. Boredom of Old Age
Case 1: As your community’s psychogeriatric resource nurse, you
are asked to call on Mrs. Borg, a 92 year old widowed lady with no
past medical or psychiatric history living on her own with some
support from a home help worker 1 hour per day. You are told that
she has been acting strangely over the past few months, talking of
little people visiting her at night and observing unusual images on
her walls. You are told that her memory has declined over the past
few months and needs support in most iADL’s but is independent
of ADL’s. At this time your primary/working diagnosis is:
A. Late-Onset Schizophrenia
B. Psychosis Secondary to a Medical Illness
C. Dementia
D. Depression with Psychotic Symptoms
E. Boredom of Old Age
Case 1 continued: The most critical aspect of your assessment of
Mrs. Borg involves:
A. Obtaining detailed history from reliable informant
B. Establish Personal and Developmental History
C. Checking her Vital Signs and Doing a MMSE
D. Rule out Schizophrenia
E. A & C
F. All the Above
Case 1 continued: The most critical aspect of your assessment of
Mrs. Borg involves:
A. Obtaining detailed history from reliable informant
B. Establish Personal and Developmental History
C. Checking her Vital Signs and Doing a MMSE
D. Rule out Schizophrenia
E. A & C
F. All the Above
Case 1 continued: Having established your provisional diagnosis,
you consider your next step. As a thorough clinician accustomed
to deal with severe mental illness and trained to maintain calm
and use emergency resources carefully given current constraints
on emergency medical resources and hospital beds, you decide
to:
A. Arrange an urgent Crisis Team Appointment the Next Day
B. Arrange Appointment at POP next week and involve Outreach
Services in the Meanwhile
C. Inform your supervisor and document your discussion
D. Counsel the Caregiver about Dementia
B. None of the Above
Case 1 continued: Having established your provisional diagnosis,
you consider your next step. As a thorough clinician accustomed
to deal with severe mental illness and trained to maintain calm
and use emergency resources carefully given current constraints
on emergency medical resources and hospital beds, you decide
to:
A. Arrange an urgent Crisis Team Appointment the Next Day
B. Arrange Appointment at POP next week and involve Outreach
Services in the Meanwhile
C. Inform your supervisor and document your discussion
D. Counsel the Caregiver about Dementia
B. None of the Above
Medical Causes of Psychosis
with or without delirium
(MINES)
Metabolic
B12 and Folate Def
Electrolyte Abnormalities
Infections
Encephalitis
Meningitis
Syphilis
HIV
Neurologic
Parkinson’s, Epilepsy, Strokes,
Subdural hematomas, huntington’s,
tumor.
Endocrine
Thyroid, Parathyroid, Adrenal, hyperand hypo- glycemia.
Substances
Intoxication or Withdrawal
Benzodiazepines, Alcohol
Narcotics,
Anticholinergics,
Case 2: The Hidden Pain
Case 2: As the local psychogeriatric resource nurse, you are called on a 70 year
old man recently admitted to a nursing home who has recently been getting
increasingly intermittently agitated, pacing the halls all day, and getting very
confused, paranoid, and physically abusive at night. You learn that he has been
recently discharged from your local rehab facility where he was treated for a
urinary tract infection. You are told that he suffers from hypertension which has
been managed with medication, and a history of dementia, but you note that his
recent discharge summary does not indicate a diagnosis of dementia, and that
he was previously living fairly independently at his own home. You find the
patient seated in a chair. He is very pleasant, but fidgety. He starts a
conversation about his past involvement with a local soccer team, and you are
impressed by how articulate he is. Yet, he is also very distractible, often loosing
track of the conversation. You conduct an MMSE scoring 21/30, yet his clock
drawing is surprisingly good. His vitals reveal a pulse rate of 110 bpm, and BP
145/90. He appears uncomfortable but is unable to tell you why. Your plan
involves:
A. Getting a verbal order for risperidone 1 mg stat
B. Counsel the staff about the management of BPSD
C. Arrange for a physical examination to be done
Case 2: As the local psychogeriatric resource nurse, you are called on a 70 year
old man recently admitted to a nursing home who has recently been getting
increasingly intermittently agitated, pacing the halls all day, and getting very
confused and verbally abusive at night. You learn that he has been recently
discharged from your local rehab facility where he was treated for a urinary tract
infection. You are told that he suffers from hypertension which has been
managed with medication, and a history of dementia, but you note that his recent
discharge summary does not indicate a diagnosis of dementia, and that he was
previously living fairly independently at his own home. You find the patient
seated in a chair. He is very pleasant, but fidgety. He starts a conversation about
his past involvement with a local soccer team, and you are impressed by how
articulate he is. Yet, he is also very distractible, often loosing track of the
conversation. You conduct an MMSE scoring 21/30, yet his clock drawing is
surprisingly good. His vitals reveal a pulse rate of 110 bpm, and BP 145/90. He
appears uncomfortable but is unable to tell you why. Your plan involves:
A. Getting a verbal order for risperidone 1 mg stat
B. Counsel the staff about the management of BPSD
C. Arrange for a physical examination to be done
Delirium
• A sudden and significant decline in
mental functioning not better accounted
for by a preexisting or evolving
dementia
• Disturbance of consciousness with
reduced ability to focus, sustain, and
shift attention
4 major causes
•
•
•
•
Underlying medical condition
Substance intoxication
Substance withdrawal
Combination of any or all of these
Causes
of
Delirium
(I WATCH DEATH)
Infections
Deficiencies
Withdrawals
Endocrinopathies
Acute Metabolic
Acute Vascular
Trauma
Toxins or Drugs
CNS Pathology
Heavy Metals
Hypoxia
Causes
of
Delirium
(I WATCH DEATH PAIN)
Infections
Deficiencies
Withdrawals
Endocrinopathies
Acute Metabolic
Acute Vascular
Trauma
Toxins or Drugs
CNS Pathology
Heavy Metals
Hypoxia
PAIN
Prevalence
• Hospitalized medically ill: 10-30%
• Hospitalized elderly: 10-40%
• Postoperative patients: up to 50%
• Near-death terminal patients: up to
80%
Clinical features
Prodrome
Fluctuating course
Attentional deficits
Arousal /psychomotor disturbance
Impaired cognition
Sleep-wake disturbance
Altered perceptions
Affective disturbances
Beware of the “quiet”
delirium…
• Hyperactive (agitated, hyperalert)
• Hypoactive (lethargic, hypoalert)
• Mixed
Outcome
• Elderly patients 22-76% chance of dying
during that hospitalization
• Several studies suggest that up to 25%
of all patients with delirium die within 6
months
Management
• Environmental interventions
- “Timelessness”
- Sensory impairment (vision, hearing)
- Orientation cues
- Family members
- Frequent reorientation
- Nightlights
Management
• Pharmacologic management of agitation
- Low doses of high potency neuroleptics
(i.e. haloperidol) – po, im or iv
- Atypical antipsychotics (risperidone)
Benzodiazepines generally restricted to
withdrawal situations as they may cause
paradoxical reactions
Case 3: Je Me Souviens
Case 3: An 81 year old man has been seeing his dead wife and dead sister for
the past three months. He has a 4 year history of declining memory and
difficulties with iADL’s. His daughter reminds you that he has a history of
recurrent bouts of depression, and you note that he has been crying and having
difficulty sleeping, and calling her incessantly and getting very anxious when she
is about to leave. You are a seasoned nurse and recognize the importance of a
physical and cognitive evaluation in such situations, and note that his BP is
165/90, PR normal, afebrile, but appears mildly rigid in his upper and lower
extremities, and he shuffles somewhat when he walks. MMSE is 17/30, and his
attention span during your assessment is excellent. His daughter shows you
results from recent tests done in hospital stating that his CT brain was
unremarkable except for mild atrophy The most likely explanation of this
presentation is:
A. Parkinson’s Disease with Dementia
B.Severe Depression with Psychotic Symptoms
C.Alzheimer’s Disease
D.Late-Onset Schizophrenia
E.Lewy-Body Dementia
Case 3: An 81 year old man has been seeing his dead wife and dead sister for
the past three months. He has a 4 year history of declining memory and
difficulties with iADL’s. His daughter reminds you that he has a history of
recurrent bouts of depression, and you note that he has been crying and having
difficulty sleeping, and calling her incessantly and getting very anxious when she
is about to leave. You are a seasoned nurse and recognize the importance of a
physical and cognitive evaluation in such situations, and note that his BP is
165/90, PR normal, afebrile, but appears mildly rigid in his upper and lower
extremities, and he shuffles somewhat when he walks. MMSE is 17/30, and his
attention span during your assessment is excellent. His daughter shows you
results from recent tests done in hospital stating that his CT brain was
unremarkable except for mild atrophy The most likely explanation of this
presentation is:
A. Parkinson’s Disease with Dementia
B.Severe Depression with Psychotic Symptoms
C.Alzheimer’s Disease
D.Late-Onset Schizophrenia
E.Lewy-Body Dementia
Psychosis
in
Alzheimer’s
Dementia
Very Common (20% in Early; 50% by Years 3 & 4)
Most Common in Early to Moderate Stages
Delusions and/or Hallucinations
Hallucinations (Visual > auditory > others)
Delusions (Commonly “understandable” false
beliefs – e.g. delusions of theft, house is not home,
persecution); these decrease in later stages.
? Psychosis associated with more rapid decline
http://www.alzheimers.org.uk
‘Management of Behavioural Changes
in Individuals with Dementia’
by Dr Carmelo Aquilina
Wednesday 14th March 2012
Time: 6:30pm-7:30pm
Venue: 5, Lion Street, Floriana
Case 4: Slow, Unsteady, and Scared
Case 4: A 75 year old woman reports hallucinations of children and small
animals when she is alone in her room. Her family describe her getting very
agitated when this happens. On your functional inquiry they respond that she
has been having more difficulty walking, and at times has some tremor in her
hands. Aware that dementia is a a very common cause of hallucinations in the
elderly, you inquire about her memory. Her daughter acknowledges that she
noted a small but noticeable decline in recent memory over the past year, with a
tendency to repeat questions, difficulties with finding the right words, getting lost
when shopping, and preparing meals. The daughter also noticed that her state
tends to fluctuate somewhat, having some “good days” in which she seems quite
well in terms of her memory and even her tremor. Your examination is
unremarkable except for some rigidity in her arms and mild resting tremor. The
most likely explanation of this presentation is:
A. Parkinson’s Disease with Dementia
B.Severe Depression with Psychotic Symptoms
C.Alzheimer’s Disease
D.Late-Onset Schizophrenia
E.Lewy-Body Dementia
Case 4: A 75 year old woman reports hallucinations of children and small
animals when she is alone in her room. Her family describe her getting very
agitated when this happens. On your functional inquiry they respond that she
has been having more difficulty walking, and at times has some tremor in her
hands. Aware that dementia is a a very common cause of hallucinations in the
elderly, you inquire about her memory. Her daughter acknowledges that she
noted a small but noticeable decline in recent memory over the past year, with a
tendency to repeat questions, difficulties with finding the right words, getting lost
when shopping, and preparing meals. The daughter also noticed that her state
tends to fluctuate somewhat, having some “good days” in which she seems quite
well in terms of her memory and even her tremor. Your examination is
unremarkable except for some rigidity in her arms and mild resting tremor. The
most likely explanation of this presentation is:
A. Parkinson’s Disease with Dementia
B.Severe Depression with Psychotic Symptoms
C.Alzheimer’s Disease
D.Late-Onset Schizophrenia
E.Lewy-Body Dementia
Psychosis in Lewy Body Dementia
Very Common (visual hallucinations up to 80%;
often an early sign)
Auditory hallucinations (20%) and paranoid
delusions (65%) also common
Therefore, overall at least as common (if not more)
compared with psychosis in AD
Important to recognize due to (a) high sensitivity to
even low doses of antipsychotics (especially high
potency), (b) greater risk of falls, (c) sleep
disorders, (d) fluctuating and more rapid course.
Psychosis in Parkinson’s Disease
Also very Common (20 – 60%, more so in later
stages with dementia)
Hallucinations more common than delusions (often
vivid visual hallucinations)
Hallucinations most commonly secondary to
dopaminergic medication (rather than due to PD
per se).
Onset of Sx vis-à-vis medication dosing times /
new treatment can give clues to etiology.
Case 5: The Intruder
Case 5: You conduct a home visit for a a very pleasant and seemingly
cognitively intact 69 year old woman who has become a local nuisance with the
police and neighbors over the past 7 months, making frequent reports about “the
woman next door entering” her home. She cites a number of pieces of
“evidence” for her case, including lights and noises she hears at night, and a
“fallen toothpick” which she placed in her key hole to check whether anyone has
tried to force her door open. She has no psychiatric history, has been generally
well physically except for a declining hearing and vision. You call her son from
her home and he informs you that his mother was never unwell, though in
hindsight she always tended to be somewhat “sensitive” and suspicious of
others’ motives. He confirms that she has never abused alcohol or drugs. She
has evidently been taking very good care of herself and her house, and while
she has tended to avoid going out, she has no difficulty walking. On your
examination you notice that except for very mild forgetfulness (MMSE 27/30) she
is physically intact and her mental status is otherwise unremarkable. The most
likely explanation of this presentation is:
A. Bipolar Disorder
B. Alzheimer’s Disease
C. Delusional Disorder
D. Paranoid Personality Disorder
Case 5: You conduct a home visit for a a very pleasant and seemingly
cognitively intact 69 year old woman who has become a local nuisance with the
police and neighbors over the past 7 months, making frequent reports about “the
woman next door entering” her home. She cites a number of pieces of
“evidence” for her case, including lights and noises she hears at night, and a
“fallen toothpick” which she placed in her key hole to check whether anyone has
tried to force her door open. She has no psychiatric history, has been generally
well physically except for a declining hearing and vision. You call her son from
her home and he informs you that his mother was never unwell, though in
hindsight she always tended to be somewhat “sensitive” and suspicious of
others’ motives. He confirms that she has never abused alcohol or drugs. She
has evidently been taking very good care of herself and her house, and while
she has tended to avoid going out, she has no difficulty walking. On your
examination you notice that except for very mild forgetfulness (MMSE 27/30) she
is physically intact and her mental status is otherwise unremarkable. The most
likely explanation of this presentation is:
A. Bipolar Disorder
B. Alzheimer’s Disease
C. Delusional Disorder
D. Paranoid Personality Disorder
Delusional Disorder
•
Relatively uncommon (0.03%) but more common in older adults
•
Different from Schizophrenia in lack of hallucinations, absence of
deterioration of function, and generally absence of
disorganization of behavior and certainly of thought.
•
Different from Dementia in absence of Cognitive Decline
•
Different from Mood Disorder: No preceding mood component
•
Often find premorbid history of paranoid and schizotypal
personalities
•
Difficult to manage/treat as they deny illness and refuse
medication (but AP’s are effective, if taken..); CBT approaches
can be helpful.
Case 6: Looming Death
Case 6: A previously healthy 70-year old woman is admitted to KGH for failure to
thrive. She has lost 20 Kg in the past 7 months, has difficulty swallowing solids
and liquids, and has lost her appetite entirely. Previously the life of her family,
she no longer enjoys visits from her children, and would rather be left alone.
Physical examinations, laboratory tests, imaging and endoscopy have yielded no
positive results. You are part of a psychogeriatric consultation service and asked
to see patient to rule out a “psychosomatic illness”. You find a cachectic woman
seated in her chair. She is difficult to engage, makes little eye contact, and
shows marked latency of speech. When you ask her why she is not eating she
points to her throat and says that the “feeding tube is clogged”. Her affect is
dysphoric but blunted in reactivity and shows very limited range. When asked
what she believes is the root of her problem she indicates that she has a
terminal cancer. You note that she has resigned herself to dying, and sees no
scope for living any further. Mention of her large family elicits no emotion from
her. Cognitively she is difficult to assess fully as her ability to focus and persist
on tasks is limited. However she is clearly alert, well-oriented to exact place, and
oriented to time o the year. Recent memory appears mildly impaired, though
formal testing not done. The most likely explanation of this presentation is:
A. Major Depressive Episode with Psychotic Symptoms
B. Schizoaffective Disorder, Depressed State
C. Occult Gastric Carcinoma
Case 6: A previously healthy 70-year old woman is admitted to KGH for failure to
thrive. She has lost 20 Kg in the past 7 months, has difficulty swallowing solids
and liquids, and has lost her appetite entirely. Previously the life of her family,
she no longer enjoys visits from her children, and would rather be left alone.
Physical examinations, laboratory tests, imaging and endoscopy have yielded no
positive results. You are part of a psychogeriatric consultation service and asked
to see patient to rule out a “psychosomatic illness”. You find a cachectic woman
seated in her chair. She is difficult to engage, makes little eye contact, and
shows marked latency of speech. When you ask her why she is not eating she
points to her throat and says that the “feeding tube is clogged”. Her affect is
dysphoric but blunted in reactivity and shows very limited range. When asked
what she believes is the root of her problem she indicates that she has a
terminal cancer. You note that she has resigned herself to dying, and sees no
scope for living any further. Mention of her large family elicits no emotion from
her. Cognitively she is difficult to assess fully as her ability to focus and persist
on tasks is limited. However she is clearly alert, well-oriented to exact place, and
oriented to time o the year. Recent memory appears mildly impaired, though
formal testing not done. The most likely explanation of this presentation is:
A. Major Depressive Episode with Psychotic Symptoms
B. Schizoaffective Disorder, Depressed State
C. Occult Gastric Carcinoma
Affective Psychosis
Psychotic Depression present in up to 50% of
hospitalized elderly patients with depression, and
25% of community dwelling elderly with depression
Delusions (mood-congruent) much more common
than hallucinations.
Catatonia in severe depression
Bipolar mania also generally presents with moodcongruent delusions (e.g. erotomanic)
The Older Patients with Schizophrenia
Schizophrenia and Aging
• Rate of Cognitive Decline not different from
general population (but they often start from a
lower baseline and “appear” demented early!!)
• Aud Halluc and Delusions may decrease
• Negative Symptoms may increase
• Older patients with schizophrenia have a
worse functional outcome than patients with
HIV-AIDS
Prescribed Antipsychotic Dose and Age
1,418 patients in Tokyo
Inpatients
Outpatients
Uchida H et al. Am J Geriatr Psychiatry (2008)
Age and D2
Dean F Wong et al
Uchida et al
Antipsychotic Dosing Recommendations
in Older Patients with Schizophrenia
 Up to 40 % reduction in dose > 45yrs
(Harris 1997)
 Up to 60 % reduction in dose (mixed age)
(Inderbitzin 1994; Smith 1994)
 Expert Consensus
(Alexopoulos GS et al 2004)
Risperidone 1.25 – 3.5 mg
Olanzapine 7.5 – 15 mg
Quetiapine 100 – 300 mg
Classical pharmacokinetics does
not address variability
Percent Responders (CGI)
LAST PIECE OF THE PUZZLE
100
80
60
Non Responders
Responders
40
20
0
<65%
> 65%
Striatal D2 Occupancy
∆ Dose
Therapeutic Window
Population Pharmacokinetics
Maintain
Wellness
“Grow old with me!
The best is yet to be,
the last of life,
for which the first was made..”
Robert Browning