The Incidence of Nonaffective, Nonorganic Psychotic Disorders in Older People: A Population-based Cohort Study of 3 Million People in Sweden

Grief as a Risk Factor for Psychosis: A Systematic Review

PURPOSE OF REVIEW

The assessment of the risk of triggering psychosis upon exposure to grief is a challenge in clinical practice. Adequate diagnosis and early prevention are essential and may be helpful in the evolution of normal grief. We aimed to identify studies exploring grief as a risk factor for developing psychosis.

RECENT FINDINGS

A systematic review of 3 databases (PubMed, EMBASE, and Cochrane Library) was conducted.

RESULTS

In the first approach 618 studies were identified. After the selection process, 15 studies were included in the review. The association between grief and the risk of developing psychosis occurred at younger ages (before 18 years of age) in a first-degree relative and as a consequence of suicide or accidental death. We found that risk factors such as comorbidity, mental problems, unemployment, economic difficulties, and close ties with the deceased have a negative impact on health causing greater vulnerability to psychosis with a risk of developing complicated grief, with statistically significant results regarding the associations between early parental death and the probability of developing psychosis in adulthood.

Enhancing identification of nonaffective psychosis in register-based studies

The Finnish Quality of Psychosis Care Register assesses nonaffective psychosis (NAP) care, acknowledging treatment outside specialized psychiatric services. This approach, while providing a holistic view, raises concerns about diagnostic inaccuracies. Here, we studied situations where the register-based diagnosis might be inaccurate, and whether the first episode can be reliably identified using a 14-year wash-out period. People with first register-based NAP (ICD-10 F20-F29) between years 2010 and 2018 and without NAP diagnoses in 1996-2009 were identified from the Care Register for Health Care. A diagnosis of NAP was deemed unreliable before age 7, when dementia preceded NAP diagnosis, and when a NAP diagnosis had been assigned at admission or during psychiatric hospitalization but was not confirmed by discharge diagnosis. Despite a 14-year follow-back the first register diagnosis may miss the first treatment episode in older patients. Register-based studies on psychotic disorders should pay attention to exclusion criteria and to the definition of treatment onset.

New horizons in schizophrenia in older people

People aged 65 years and older will soon constitute more than a quarter of the total population with schizophrenia, challenging the existing systems of care. For a long time, research into schizophrenia in later life was very limited. However, recent years have seen an encouraging surge in novel and high-quality studies related to this stage of life. Older people with schizophrenia consist of those who had an early onset and aged with the disorder, and of a smaller but sizeable group with a late onset or a very late onset. With ageing, physical needs gain importance relative to psychiatric needs. Medical comorbidity contributes to a markedly higher mortality compared to the general population. In many persons, symptoms and functioning fluctuate with time, leading to deterioration in some but improvement in others. Of note, a substantial number of older people may experience subjective well-being in spite of ongoing symptoms and social impairments. The majority of individuals with schizophrenia reside in the community, but when institutionalization is required many are placed in residential or nursing homes where staff is often ill-equipped to address their complex needs. There is a clear need for implementation of new models of care in which mental health and general health systems cooperate. This review provides a state-of-the-art overview of current knowledge in late life schizophrenia and related disorders, with a focus on themes with clinical relevance.

Investigating the association between schizophrenia and distance visual acuity: Mendelian randomisation study

BACKGROUND

Increased rates of visual impairment are observed in people with schizophrenia.

AIMS

We assessed whether genetically predicted poor distance acuity is causally associated with schizophrenia, and whether genetically predicted schizophrenia is causally associated with poorer visual acuity.

METHOD

We used bidirectional, two-sample Mendelian randomisation to assess the effect of poor distance acuity on schizophrenia risk, poorer visual acuity on schizophrenia risk and schizophrenia on visual acuity, in European and East Asian ancestry samples ranging from approximately 14 000 to 500 000 participants. Genetic instrumental variables were obtained from the largest available summary statistics: for schizophrenia, from the Psychiatric Genomics Consortium; for visual acuity, from the UK Biobank; and for poor distance acuity, from a meta-analysis of case-control samples. We used the inverse variance-weighted method and sensitivity analyses to test validity of results.

RESULTS

We found little evidence that poor distance acuity was causally associated with schizophrenia (odds ratio 1.00, 95% CI 0.91-1.10). Genetically predicted schizophrenia was associated with poorer visual acuity (mean difference in logMAR score: 0.024, 95% CI 0.014-0.033) in European ancestry samples, with a similar but less precise effect that in smaller East Asian ancestry samples (mean difference: 0.186, 95% CI -0.008 to 0.379).

CONCLUSIONS

Genetic evidence supports schizophrenia being a causal risk factor for poorer visual acuity, but not the converse. This highlights the importance of visual care for people with psychosis and refutes previous hypotheses that visual impairment is a potential target for prevention of schizophrenia.

Association between risk of dementia and very late-onset schizophrenia-like psychosis: a Swedish population-based cohort study

BACKGROUND

Although the incidence of psychotic disorders among older people is substantial, little is known about the association with subsequent dementia. We aimed to examine the rate of dementia diagnosis in individuals with very late-onset schizophrenia-like psychosis (VLOSLP) compared to those without VLOSLP.

METHODS

Using Swedish population register data, we established a cohort of 15 409 participants with VLOSLP matched by age and calendar period to 154 090 individuals without VLOSLP. Participants were born between 1920 and 1949 and followed from their date of first International Classification of Diseases [ICD], Revisions 8-10 (ICD-8/9/10) non-affective psychotic disorder diagnosis after age 60 years old (or the same date for matched participants) until the end of follow-up (30th December 2011), emigration, death, or first recorded ICD-8/9/10 dementia diagnosis.

RESULTS

We found a substantially higher rate of dementia in individuals with VLOSLP [hazard ratio (HR): 4.22, 95% confidence interval (95% CI) 4.05-4.41]. Median time-to-dementia-diagnosis was 75% shorter in those with VLOSLP (time ratio: 0.25, 95% CI 0.24-0.26). This association was strongest in the first year following VLOSLP diagnosis, and attenuated over time, although dementia rates remained higher in participants with VLOSLP for up to 20 years of follow-up. This association remained after accounting for potential misdiagnosis (2-year washout HR: 2.22, 95% CI 2.10-2.36), ascertainment bias (HR: 2.89, 95% CI 2.75-3.04), and differing mortality patterns between groups (subdistribution HR: 2.89, 95% CI 2.77-3.03).

CONCLUSIONS

Our findings demonstrate that individuals with VLOSLP represent a high-risk group for subsequent dementia. This may be due to early prodromal changes for some individuals, highlighting the importance of ongoing symptom monitoring in people with VLOSLP.

Four-repeat tauopathies and late-onset psychiatric disorders: Etiological relevance or incidental findings?

Argyrophilic grain disease (AGD), progressive supranuclear palsy (PSP) and corticobasal degeneration are four-repeat (4R) tauopathies that develop in the presenium or later. Whether these diseases are associated with the occurrence of late-onset psychiatric disorders remains unclear. To facilitate the accumulation of clinicopathological findings regarding this issue, we here present a selected series of 11 cases that clinically developed psychotic disorder (n = 7; age at onset: 41-75 years), depressive disorder (n = 1; 49 years), bipolar disorder (n = 2; 32 and 37 years) and somatoform disorder (n = 1; 88 years), and had at least one pathological hallmark of these tauopathies. The mean age at death was 74.3 years. No case showed dementia, at least in the early stage of the course. Nine cases had AGD. Granular fuzzy astrocytes in the amygdala were noted in all AGD cases and one non-AGD case. Two AGD cases had tufted astrocytes (TAs) in the amygdala but not in the frontal cortex and striatum. Three AGD and two non-AGD cases had TAs in the frontal cortex and/or striatum but not in the amygdala. One AGD case had a small number of astrocytic plaques in the frontal cortex, striatum and globus pallidus. Only one case was diagnosed as atypical PSP according to the NINDS-PSP neuropathological criteria. No case had high-level Alzheimer's disease pathology, Lewy body disease or limbic-predominant age-related TDP-43 encephalopathy. Two cases had mild neuronal loss in the hippocampus and substantia nigra, respectively. Clinicopathological studies focusing especially on early changes of 4R tauopathies, as well as the development of surrogate markers of these diseases, may be necessary for better understanding of the pathogenic backgrounds of late-onset psychiatric disorders.

Non-affective psychotic disorders and risk of dementia: a systematic review and meta-analysis

Non-affective psychotic disorders have been associated with an increased risk of developing dementia. However, research in this area remains limited, highlighting the need for an up-to-date systematic review and meta-analysis of the evidence. We aimed to systematically review and quantify the risk of dementia associated with psychotic disorders. We searched four electronic databases for longitudinal studies investigating non-affective psychotic disorders and subsequent dementia. We used random-effects meta-analyses to pool estimates across studies and assessed risk of bias for each study. Non-affective psychotic disorders were associated with increased risk of all-cause dementia; pooled risk ratio (RR) = 2.52, 95% confidence interval (CI) (1.67-3.80), I2 = 99.7%, n = 12,997,101; 11 studies, with high heterogeneity between studies. Subgroup analyses indicated stronger associations in studies with shorter follow-up periods, conducted in non-European countries, published after 2020, and where ≥60% of the sample were female. The risk was higher in people aged <60 years at baseline, in typical and late-onset psychotic disorders versus very late-onset psychosis, in broader psychotic disorders vs schizophrenia, and in prospective vs retrospective studies. Associations remained after excluding low quality studies (pooled RR = 2.50, 95% CI (1.71-3.68), I2 = 99.0%). Our review finds a substantial association between psychotic disorders and subsequent dementia. Our findings indicate that psychotic disorders are a potentially modifiable risk factor for dementia and suggest that individuals with psychotic disorders need to be closely monitored for cognitive decline in later life. Further research is needed to investigate the mechanisms underlying the association between psychotic disorders and dementia.

Prevalence, clinical features, and risk factors of delusions in patients with delirium

OBJECTIVES

Delirium may be divided into multiple subtypes with different pathological factors. This study aimed to focus on the delirium subtype in which delusions are conspicuous and explore its prevalence, clinical characteristics, and risk factors.

METHODS

The subjects were 601 delirium cases referred to the department of psychiatry over 5 years at a general hospital. The Delirium Rating Scale-Revised-98 was used to assess the delusions in patients with delirium, and the features of delusions (delusional form, object, and content) were examined. Multiple regression analysis was applied to determine whether individual factors were associated with the delusions.

RESULTS

A total of 78 patients with delirium experienced delusions (13.0%). Most were classified as delusion of reference, such as persecution or poisoning, and 84.3% of patients believed that the persecutors were medical staff members. Older age (p < 0.001), female gender (p < 0.001), and living alone (p < 0.001) were significantly associated with delusions in patients with delirium.

CONCLUSIONS

The content of delusions was rooted in the distress caused by the patients' medical situation, and the features and risk factors of the delusions suggested a formal similarity with late paraphrenia and "lack-of-contact paranoia." Psychological interventions that consider the isolation, anxiety, and fear behind delusions may be necessary in the care and treatment of these patients.

Factors associated with late-life psychosis in primary care older adults without a diagnosis of dementia

PURPOSE

The epidemiology of late-life psychosis (LLP) remains unclear comparatively to early-onset psychosis. The study aims to estimate the prevalence and incidence of LLP over a 3-year period and examine the correlates of LLP in community-living older adults aged ≥ 65 years recruited in primary care.

METHODS

Study sample included N = 1481 primary care older adults participating in the Étude sur la Santé des Aînés (ESA)-Services study. Diagnoses were obtained from health administrative and self-reported data in the 3 years prior and following baseline interview. The prevalence and incidence of LLP (number of cases) were identified in the 3-year period following interview. Participants with dementia or psychosis related to dementia were excluded. Logistic regressions were used to ascertain the correlates of LLP as function of various individual and health system factors.

RESULTS

The 3-year prevalence and incidence of LLP was 4.7% (95% CI = 3.64-5.81) and 2.8% (95% CI = 1.99-3.68), respectively. Factors associated with both prevalent and incident LLP included functional status, number of physical diseases, hospitalizations, continuity of care and physical activity. Older age and the presence of suicidal ideation were associated with incident LLP, while higher education, a depressive disorder and a history of sexual assault were associated with persistent cases.

CONCLUSIONS

Results highlight the importance of LLP in primary care older adult patients without dementia. Health system factors were consistent determinants of prevalent and incident LLP, suggesting the need for better continuity of care in at-risk primary care older adults.

Crossroad between current knowledge and new perspective of diagnostic and therapy of late-onset schizophrenia and very late-onset schizophrenia-like psychosis: An update

Schizophrenia is a chronic, highly individualized disease with many symptoms that can occur with varying severity in different patients. Schizophrenia affects 1% of the population, but occurs in almost 20% of patients after 40 years of age. It should be noted that the next peak in the incidence of schizophrenia occurs at the age of 60 years, affects mostly females, and is closely associated with a high risk of developing memory disorders. Therefore, postadolescent schizophrenia includes two distinct groups of patients: those whose symptoms onset at the age of 45 or 60. The purposes of this literature review were as follows: (1) synthetically characterize the clinical manifestations of schizophrenia; (2) discuss difficulties in the diagnosis of schizophrenia, especially in patients over 40 years of age; (3) discuss the clinical utility of different classes of marker in diagnostic and differentiating schizophrenia from neurodegenerative diseases in elderly people; (4) discuss therapeutic options for schizophrenia, pharmacotherapy, and psychotherapy, emphasizing the role of caregivers of people with psychosis in therapy, in preadolescence and postadolescence schizophrenia. We have tried to primarily discuss the findings of original articles from the last 10 years with an indication of their clinical implications with the issues discussed in the various subsections. Moreover, despite many years of research, no specific, precise algorithm has been developed that can be used in clinical practice during the diagnosis of schizophrenia. For this reason, the diagnosis of schizophrenia is primarily based on an interview with the patient and his family, as well as on the experience of a psychiatrist. It also seems that schizophrenia treatment should be carried out holistically, including pharmacotherapy, psychotherapy, and the support of caregivers of patients who have this psychosis, which increases the achievement of therapeutic success. Finally, we must be aware of the difficulties in diagnosing schizophrenia in the elderly and the need to modify pharmacological treatment. Currently, no guidelines have been developed for the differentiation of negative symptoms in elderly patients with schizophrenia from amotivation/avolition/apathy symptoms in elderly patients with neurodegenerative disorders.

A case report of late-onset schizophrenia differentiated from a dementing disorder

We report a case of late-onset schizophrenia that required differentiation from a dementing disorder. The patient was an 83-year-old woman who had experienced auditory hallucinations since she was 67 years old. The patient had slightly elevated total tau and slightly decreased amyloid β1-42, cerebrospinal fluid biomarkers. This case was identified as late-onset schizophrenia. However, the results of cerebrospinal fluid biomarkers indicated that neurofibrillary tangles and neuronal death, which are characteristic of Alzheimer 's disease, may also have been present. Late-onset schizophrenia should be treated based on an appropriate differential diagnosis, including neuropathological consideration of dementing disorders.

Association Between Childhood Visual Acuity and Late Adolescent Psychotic Experiences: A Prospective Birth Cohort Study

A cross-sectional association between visual impairment and psychosis exists, but longitudinal evidence from children and young people is limited. We investigated whether childhood visual acuity was associated with subsequent psychotic experiences. Our sample was 6686 individuals from the Avon Longitudinal Study of Parents and Children (ALSPAC). We investigated whether our primary exposures, best corrected visual acuity at ages 7 and 11, were associated with psychotic experiences at ages 17 and 24. We also tested whether the following exposures at ages 7 and 11 were associated with subsequent psychotic experiences: requiring glasses, presence of any visual impairment, and between-eye visual acuity difference; and at age 7: strabismus, measures of binocular vision, history of eye patch, near vision impairment, and abnormal saccadic or pursuit eye movements. Analyses used multilevel models before and after adjusting for confounders. Odds of psychotic experiences increased with each 0.1-point deterioration in visual acuity score at age 11 (adjusted odds ratio [AOR] 1.23; 95% confidence interval [CI] 1.06-1.42), and at age 7 (AOR 1.18; 95% CI 1.00-1.40). Wearing glasses and visual impairment at age 11 were associated with psychotic experiences (AOR 1.63; 95% CI 1.21-2.19; AOR 1.64; 95% CI 1.23-2.19, respectively). There was no evidence of an association with other visual exposures. Visual acuity impairment in childhood is associated with psychotic experiences in late adolescence. Future research should aim to elucidate the nature of this association.

Stratification by Sex and Hormone Level When Contrasting Men and Women in Schizophrenia Trials Will Improve Personalized Treatment

BACKGROUND

Sex and gender differences have been reported in the prevalence, expression, treatment response, and outcome of schizophrenia, but most reports are based on relatively small samples that have not been stratified for the impact of sex hormone levels. This literature review aims to show how women's hormone levels can impact the results of male/female comparisons.

METHODS

This is a narrative review of data from publications of the last decade.

RESULTS

Epidemiologic evidence, reports of the impact of hormones on cognition, results of sexually dimorphic responses to treatment, and male/female trajectories of illness over time all suggest that female hormone fluctuations exert major effects on male/female differences in schizophrenia.

CONCLUSIONS

Information on hormonal status in women participants is rarely available in clinical studies in schizophrenia, which makes male/female comparisons largely uninterpretable. These are the current challenges. Opportunities for individualized treatment are growing, however, and will undoubtedly result in improved outcomes for both women and men in the future.

Associations between psychosis and visual acuity impairment: A systematic review and meta-analysis

OBJECTIVES

Several theories propose that visual acuity impairment is associated with psychosis. Visual impairment could lead to psychosis or the converse, or they may share underlying pathology or risk factors. In the first evidence synthesis in this area for over 25 years, we collated studies measuring the association between visual acuity impairment and psychosis.

METHODS

We searched the MEDLINE, EMBASE, PsycINFO, and Web of Science databases for studies published from 1992 to 2020, using the Newcastle Ottawa Scale to assess risk of bias. We narratively synthesized findings and meta-analyzed sufficiently homogenous results.

RESULTS

We included 40 papers, which reported on 31 studies. Evidence from seven cohort studies was inconsistent, which precluded meta-analysis of this study design. These contradictory results also made it difficult to draw conclusions regarding a temporal association. We found evidence for an association from eight cross-sectional studies treating visual acuity impairment as the exposure and psychosis as the outcome [pooled odds ratio (OR) =1.76, 95% confidence interval (CI): 1.34-2.31], and four with the reverse exposure and outcome (OR: 1.85, 95% CI: 1.17-2.92). Seven case-control studies with mixed findings were found, but only two primarily addressed our research question, and these findings were mixed.

CONCLUSIONS

Although evidence supports a cross-sectional association between visual acuity impairment and psychosis, further research is needed to clarify the temporal direction, given the mixed findings in cohort studies. Understanding the association may give insights into prevention strategies for people at risk of visual acuity impairment and psychosis.

Cachexia and Cognitive Function in the Community-Dwelling Older Adults: Mediation Effects of Oral Health

BACKGROUND

Cognitive impairment and poor oral health are common problems in older adults and are associated with malnutrition. However, it is unclear how they are related to cachexia in community-dwelling older adults. The aim of this study was to examine the relationships among cachexia, cognitive function, and oral health in community-dwelling older adults.

METHODS

This study is a secondary analysis of a data-set. Data were collected in the community setting on older adults who applied for government-funded long-term care services in Hong Kong in 2017. Subjects were community-dwelling and aged ≥60 years. The outcome variable was cachexia. The predictors were cognitive function and oral health. The covariates included demographics and comorbidities associated with cachexia or malnutrition. Path analysis was employed to examine the associations among cachexia, cognitive function, and oral health using the software SAS/STAT and Mplus.

RESULTS

This analysis included 12,940 subjects. The prevalence of cachexia was 1.3%. Cognitive function was also found to have a direct effect on the oral health indicators of chewing problems (OR=1.073, p<0.001), brushing teeth problems (OR=1.349, p<0.001), and swallowing problems (coeff.=0.177, p<0.001). Oral health indicators with a direct effect on cachexia included dry mouth (OR=1.250, p<0.001), brushing teeth problems (OR = 1.185, p<0.01), and swallowing problems (OR=1.231, p<0.001). Cognitive function had no significant direct effect, but had a significant indirect effect on cachexia (OR=1.100, p<0.001) which is mediated by brushing teeth problems (OR=1.052, p<0.001) and swallowing problems (OR=1.038, p<0.001).

CONCLUSION

Cognitive impairment causes cachexia indirectly through poor oral health. This study recommends adding cognitive function when screening community-dwelling older adults for cachexia. Health policymakers should stress regular oral health screening and interventions, and encourage increased utilization of oral health services by community-dwelling older adults with cognitive problems.

Psychotic disorders in late life: a narrative review

Psychotic disorders are not uncommon in late life. These disorders often have varied etiologies, different clinical presentations, and are associated with significant morbidity and mortality among the older adult population. Psychotic disorders in late life develop due to the complex interaction between various biological, psychological, social, and environmental factors. Given the significant morbidity and mortality associated with psychotic disorders in late life, a comprehensive work-up should be conducted when they are encountered. The assessment should not only identify the potential etiologies for the psychotic disorders, but also recognize factors that predicts possible outcomes for these disorders. Treatment approaches for psychotic disorders in late life should include a combination of nonpharmacological management strategies with the judicious use of psychotropic medications. When antipsychotic medications are necessary, they should be used cautiously with the goal of optimizing outcomes with regular monitoring of their efficacy and adverse effects.