Geriatric Delusional Depression

Psychosis in Later Life: A Review and Update

Psychosis is relatively common in later life and can present in a wide variety of contexts, including early-onset and late-onset schizophrenia, delusional disorder, mood disorders, and various dementias. It can also occur as the result of numerous medical and neurological diseases and from the use of certain medications. Although identifying the cause of psychosis in older patients can be challenging, the unique clinical features associated with the different disorders can help in making the diagnosis. Accurate diagnosis of psychosis in older populations is essential, as its treatment varies depending on the context in which it appears. Despite the safety concerns regarding the use of antipsychotics in older patients, certain pharmacological treatments appear to be both efficacious and reasonably safe in treating psychosis in older populations. Additionally, although research is limited, numerous psychosocial therapies appear promising. This review summarizes the literature on the epidemiology, clinical characteristics, neuroimaging, and treatment of psychosis in later life, and serves as an update to past reviews on this topic.

Psychotic major depression in older people: a systematic review

OBJECTIVE

This study aimed to systematically review available evidence relevant to the following issues: (1) whether psychotic major depression (PMD) in older people differs in overall severity from non-PMD, besides the presence of psychotic symptoms; (2) whether it constitutes a distinct clinical entity from non-PMD; and (3) whether it differs from PMD in younger adults.

DESIGN

A computerized MEDLINE, PsycINFO and the entire Cochrane Library search has been performed in June 2013 for prospective controlled studies investigating PMD features in older people.

RESULTS

Thirty-five relevant studies were identified. PMD in older people compared with non-PMD has been shown to present with overall more severe depressive symptomatology, more psychomotor disturbance, more guilt feelings, more depressive episodes with psychosis, worse prognosis, more severe executive dysfunction associated with frontal lobe atrophy, and lower serum dopamine β-hydroxylase activity. No differences in the efficacy of an antidepressant plus antipsychotic combination versus antidepressant monotherapy in the acute treatment as well as in the maintenance treatment were found. PMD in older patients is characterized by more somatic complaints and delusions of hypochondriacaland impending disaster content and by a lower comorbidity with anxiety disorders compared with PMD in younger adults.

CONCLUSIONS

Psychotic major depression in older people is associated with higher severity in most clinically important key features than in non-PMD. However, available evidence is still insufficient for the conclusive elucidation of its nosological status. Finally, the differences between PMD in older and younger patients can be attributed to biological and psychosocial changes of old age.

Hypochondriacal delusion in an elderly woman recovers quickly with electroconvulsive therapy

A 72-year-old woman without any medical and psychiatric history, suffered from nausea, pain in the epigastria and constipation for over a year. She eventually lost 20 kilograms despite nightly drip-feeding. Extensive additional tests did not reveal any clues for her complaints. She remained convinced that her symptoms were a side-effect of anti-fungal medication she used. She was diagnosed with hypochondria. In the course of time her ideas about her somatic symptoms became delusional and she was diagnosed with a hypochondriacal delusion as part of melancholia, without depressed mood or loss of interest or pleasure as prominent features. It is important to recognize melancholia as soon as possible by continually evaluating other symptoms of depression. This may enable to avoid repetitive and exhaustive somatic examinations, which are not indicated, and to start effective treatment. In our patient electroconvulsive therapy resulted in a fast and complete recovery.

Combination therapy with amisulpride and antidepressants: clinical observations in case series of elderly patients with psychotic depression

Psychotic depression is classified as a clinical subtype of major depressive disorder. The combination of an antidepressant with an antipsychotic agent has been demonstrated to be efficacious for the treatment of psychotic depression. However, in elderly patients with psychotic depression, little information is available on the efficacy of such combinations. Therefore, we have evaluated combination treatment for 5 weeks with amisulpride and antidepressants in non-demented elderly patients with psychotic depression. Eleven patients were treated with either citalopram 20-40 mg/day (n=5) or mirtazapine 30-60 mg/day (n=6), and amisulpride 75-100 mg/day for 5 weeks. Clinical status was evaluated at baseline and after 3 and 5 weeks using the Brief Psychiatric Rating Scale (BPRS), the Hamilton Depression Rating Scale--17 items (HDRS) and the Clinical Global Impression Scale (CGI-S). In 5 of the 11 patients there was remission of depression, while in another 5 patients there was partial remission of depression and in one patient there was no remission. Finally, there was resolution of psychotic symptoms in all the patients involved. One patient developed tremor and rigidity but insisted on continuing with the drug since her psychopathology has improved considerably after the addition of amisulpride to antidepressant treatment. In conclusion, some of the elderly patients with psychotic depression may benefit from the combination of amisulpride and antidepressant pharmacotherapy.

Aging-related diagnostic variations: need for diagnostic criteria appropriate for elderly psychiatric patients

It is commonly thought and taught that most psychiatric disorders other than dementia are much less prevalent among the elderly than among younger adults. This perception is based on a relatively small number of published epidemiologic investigations of the incidence and prevalence of mental illnesses in elderly populations. Most of these studies have had a number of methodologic problems, including improper definitions and diagnostic criteria for older persons. A likely consequence of these misconceptions is that clinically significant and potentially treatable mental illnesses might be overlooked, misdiagnosed, and mistreated in elderly patients. Studies in community samples suggest that many older adults who experience clinically significant psychopathology do not fit easily into our existing nomenclature, and yet are disabled. There is a need to develop aging-appropriate diagnostic criteria for major psychiatric disorders. In this article, we discuss the potential causes of this diagnostic confusion. Four specific classes of disorders-mood (specifically depressive) disorders, schizophrenia (and related psychotic disorders), anxiety disorders, and substance use disorders-are discussed as examples. Finally, we suggest some future steps for clarifying this diagnostic confusion.

Depression in late life: review and commentary

Depression is perhaps the most frequent cause of emotional suffering in later life and significantly decreases quality of life in older adults. In recent years, the literature on late-life depression has exploded. Many gaps in our understanding of the outcome of late-life depression have been filled. Intriguing findings have emerged regarding the etiology of late-onset depression. The number of studies documenting the evidence base for therapy has increased dramatically. Here, I first address case definition, and then I review the current community- and clinic-based epidemiological studies. Next I address the outcome of late-life depression, including morbidity and mortality studies. Then I present the extant evidence regarding the etiology of depression in late life from a biopsychosocial perspective. Finally, I present evidence for the current therapies prescribed for depressed elders, ranging from medications to group therapy.

Psychotic (delusional) major depression in late life: a clinical study

BACKGROUND

Psychotic (delusional) major depression (PMD) in the elderly is a common condition in inpatient settings. There is evidence that late age onset depressives are more likely to be psychotic.

OBJECTIVES

The aim of this study was to investigate the frequency, sociodemographic, and clinical characteristics of PMD in hospitalized elderly depressives.

METHODS

The sample consisted of 118 elderly patients consecutively admitted at three different clinics. All patients fulfilled DSM-IV criteria for major depression disorder and were diagnosed on the basis of Structured Clinical Interview for DSM-IV (SCID). The subjects were also assessed using the Hamilton Rating Scale for Depression, the Mini Mental State Examination (MMSE) and a physical health rating scale.

RESULTS

PMD was positively associated with age of depression onset over 60 [corrected]. The PMD patients were also more severely depressed, more psychomotorically retarded and referred more past psychotic depressive episodes. Furthermore, age at onset influenced the type of delusions, so that PMD patients with age [corrected] over 60 at onset expressed delusions of hypochondriacal and nihilistic content more frequently.

CONCLUSIONS

The results of our study demonstrated that PMD in the elderly has a later age at onset.