Psychotic states arising in late life (late paraphrenia). The role of risk factors

Wilhelm Mayer's follow-up study of Kraepelin's cases of paraphrenia: diagnostic validity in 1921

As part of his lifelong effort to develop optimal nosologic categories for the non-affective delusional syndromes, in the 1913 8th edition of his textbook, Kraepelin proposed a new diagnosis of paraphrenia presenting with extensive bizarre delusions and auditory hallucinations but no prominent negative symptoms or personality deterioration. He tentatively suggested it was distinct from dementia praecox (DP). His proposal was met with controversy. In an attempt to resolve this matter, Wilhelm Mayer, working with Kraepelin in Munich, published in 1921 the result of a follow-up study of the 78 cases of paraphrenia on the basis of which Kraepelin had developed his new diagnosis. In the 74 cases with adequate follow-up, Mayer's final diagnoses were 43% DP, 38% paraphrenia, and 18% other. He also presented limited family data, suggesting co-aggregation of DP and paraphrenia. On the basis of these results, Mayer argued that paraphrenia was likely better considered to represent a form of DP and not an independent disorder. His opinion was accepted by nearly all subsequent authors. Mayer's work appeared nearly a half-century before the proposal of Robin and Guze for the validation of psychiatric disorders by follow-up and family studies. The idea of deciding psychiatric questions on empirical grounds-rather than on the prestige of debating parties-is not a recent discovery but can be traced to the roots of our current diagnostic system in the work of Emil Kraepelin and his associates.

The factors associated with the presence of psychotic symptoms in the HELIAD Greek community study of older adults

BACKGROUND

The prevalence and associated factors related to psychotic symptoms in older adults are understudied. The objectives were to assess the prevalence, incidence and factors associated with psychotic symptoms in a representative Greek sample of community living older adults.

METHODS

The sample includes n = 1,904 residents of the cities of Larissa and Maroussi in Greece participating in the Hellenic Longitudinal Investigation of Aging and Diet study with available data at baseline and n = 947 individuals at the 3-year follow-up. Past-month presence of delusions and hallucinations was assessed on the grounds of the 17 symptoms of the Columbia University Scale for Psychopathology in Alzheimer's Disease and 14 symptoms of the Neuropsychiatric Inventory Questionnaire. A comprehensive neuropsychological assessment for probable diagnosis of dementia and physical comorbidity was carried out by neurologists. Penalized logistic regression analyses were used to assess the socio-economic and clinical factors associated with psychotic symptoms.

RESULTS

Past-month prevalence of psychotic symptoms was 1.9% and 1.0% when excluding cases of dementia. The prevalence of any delusion and hallucination was 0.8% and 0.3% when excluding dementia. The incidence of psychotic symptoms without dementia was 1.3%. Recent widows and farmers/breeders/craftsmen, versus public servants/teachers/executives, had both six times the odds of experiencing psychotic symptoms without dementia. Hearing impairment and the number of health conditions also increased the odds while increased age was protective.

CONCLUSION

Psychotic symptoms unrelated to dementia constitute a considerable mental health problem in old age. Paranoid delusions were the most prevalent. Socio-economic and health status factors are significant predictors of psychotic symptoms.

Experiences of Hearing Loss and Audiological Rehabilitation for Older Adults With Comorbid Psychological Symptoms: A Qualitative Study

Purpose There is a well-established relationship between hearing loss and psychological symptoms. To ensure audiological rehabilitation is provided appropriately for older adults with comorbid psychological symptoms, a greater understanding of their preferences and experiences is needed. This study sought to understand experiences of hearing loss and audiological rehabilitation from the perspective of older adults with comorbid psychological symptoms (e.g., depression, anxiety, psychosis). Design A qualitative study using in-depth semistructured interviews was conducted with older adults who had attended audiological rehabilitation within the last year and scored above established cutoffs on measures of depression, anxiety, and psychosis. A thematic analysis generated themes that related to participants' experiences of hearing loss and audiological rehabilitation. Results Participants included 14 older adults (eight men and six women) with an average age of 70.5 years (SD = 4.45, range: 64-80) who received hearing aids or a cochlear implant. Three major themes emerged from the analysis of participant interviews. "The cumulative impact of hearing loss and psychological symptoms" theme describes the two-way, additive relationship between hearing ability and psychological symptoms. "The experience of loss throughout hearing loss and audiological rehabilitation" captures subjective losses, the impact they have, and how participants cope with them. In contrast, "The experience of gain throughout hearing loss and audiological rehabilitation" describes the participants' reported gains, their related impacts, and coping strategies. Conclusions The experiences of participants revealed that the presence of comorbid psychological symptoms can influence the experience of hearing loss and audiological rehabilitation. These findings have implications for how audiological rehabilitation is provided to ensure optimal outcomes for adults with hearing loss and comorbid psychological symptoms. Supplemental Material https://doi.org/10.23641/asha.12985955.

Schizophrenia in the elderly: a special case requiring special management?

As the life expectancy of the general population increases, the population of elderly people with schizophrenia is also expected to increase. Consideration of the particular needs of these patients and the challenges associated with their management is therefore important [45].

Hearing loss and incident psychosis in later life: The Health in Men Study (HIMS)

OBJECTIVE

To determine if hearing loss is associated with increased risk of incident psychosis in later life.

METHODS

Longitudinal cohort study of a community-representative sample of 38 173 men aged 65 to 85 years at the start of the follow-up period of 18 years. We used the Western Australian Data Linkage System to ascertain the presence of hearing loss and of psychotic disorders according to the International Classification of Diseases (ICD) (versions 8, 9, and 10). We also collected information on concurrent morbidities: cancer and diseases of the cardiovascular, respiratory, digestive, and renal systems.

RESULTS

One thousand four hundred forty-two (3.8%) and 464 (1.2%) men had a recorded diagnosis of hearing loss and psychosis at the start of follow-up. After excluding the 464 participants with prevalent psychosis, 37 709 men were available for the longitudinal study, and of these, 252 (0.7%) developed a psychotic disorder. Competing risk regression showed that hearing loss was associated incident psychosis (subhazard ratio = 2.03, 95% CI, 1.24-3.32; after statistical adjustment for age and concurrent morbidities).

CONCLUSIONS

Hearing loss is associated with double the risk of incident psychosis in older men. Available evidence suggests that this link could be causal, although conclusive evidence is still missing from randomized controlled trials designed to test the effect of correction of hearing loss on the prevalence and incidence of psychosis.

Very Late-Onset Schizophrenia-Like Psychosis: A Clinical Update

Psychosis symptoms (delusions and hallucinations) are multifactorial in origin and, in later life, occur in the context of schizophrenia, delirium, dementia, delusional and schizophrenia-like disorders, mood disorders, and alcohol or substance abuse. The current article provides a clinical overview of very late-onset (after age 60) schizophrenia-like psychosis (VLOSLP), summarizing the literature on treatment options and reflecting on the role of psychiatric-mental health nurses (PMHNs). Increased awareness of the clinical presentation, key features, and evidence-based treatment options will assist PMHNs to confidently recognize this often under-diagnosed disorder and adopt a more assertive role in terms of engagement and follow up. Pragmatic research involving individuals with VLOSLP is required to increase the evidence base for treatment and improve outcomes of care. [Journal of Psychosocial Nursing and Mental Health Services, 56(1), 37-47.].

Regional cerebral blood flow in late-onset schizophrenia: a SPECT study using 99mTc-ECD

Progressive disability in schizophrenia has been considered to be associated with onset-age. The objective of this study was to evaluate age onset-related degeneration in rCBF in patients with schizophrenia. We evaluated characteristic changes in brain perfusion by age, gender, medication and clinical symptoms in medicated patients with early-onset (EOS: developed at younger than 40 years old: n = 44) and late-onset (LOS: developed at older than 40 years old: n = 19) schizophrenia and control subjects matched for age and gender (n = 37) using statistical parametric mapping (SPM8) applied to 99mTc-ECD SPECT. We performed SPECT with 99mTc-ECD on the brains of subjects. A voxel-by-voxel group analysis was performed using SPM 8 and ANOVA. rCBF in EOS was found to be reduced in the precentral and inferior frontal gyri; on the other hand, rCBF was reduced in the bilateral postcentral gyrus in LOS. This study revealed a significant difference in brain perfusion between EOS and LOS. The present study might suggest that the characteristic changes in rCBF are related to onset-age in schizophrenia.

Increased risk of psychosis in patients with hearing impairment: Review and meta-analyses

Several studies suggest hearing impairment as a risk factor for psychosis. Hearing impairment is highly prevalent and potentially reversible, as it can be easily diagnosed and sometimes improved. Insight in the association between hearing impairment and psychosis can therefore contribute to prevention of psychosis. This paper provides meta-analyses of all epidemiologic evidence on the association between hearing impairment and psychosis and summarizes mechanisms that potentially underlie this relationship. Meta-analyses showed an increased risk of hearing impairment on all psychosis outcomes, such as hallucinations (OR 1.40(95%CI 1.18-1.65; n=227,005)), delusions (OR 1.55(95%CI 1.36-1.78; n=250,470)), psychotic symptoms (OR 2.23(95%CI 1.83-2.72; n=229,647) and delirium (OR 2.67(95%CI 2.05-3.48; n=12,432). Early exposure to hearing impairment elevated the risk of later development of schizophrenia (OR 3.15(95%CI 1.25-7.95; n=50,490)). Potential mechanisms underlying this association include loneliness, diminished theory of mind, disturbances of source monitoring and top-down processing and deafferentiation. Early assessment and treatment of hearing impairment in patients with (high risk of) psychosis may be essential in psychosis treatment and prevention.

Hearing loss in persons with psychotic disorder--findings from a population-based survey

Hearing impairment is associated with psychotic symptoms, but has not been systematically studied in people with psychotic disorder. We used a population-based sample of 6654 persons aged 30+ to compare hearing, as measured by audiometry, in persons with schizophrenia, other non-affective psychosis and affective psychosis in the general population. The prevalence of hearing impairment did not differ in persons with psychotic disorder compared with the general population. Participants with schizophrenia and affective psychotic disorder had significantly more difficulties to hear in a noisy environment than the general population. Our results suggest that psychotic disorders are associated with minor hearing difficulties but not hearing impairment.

Dimensions of positive symptoms in late versus early onset psychosis

BACKGROUND

Casenote studies have characterized late onset schizophrenia (LOS) and related psychoses as somewhat different symptomatically from patients with an early onset schizophrenia (EOS). This study examined a range of phenomenological aspects of delusions and hallucinations as well as traditional symptom measures in both groups.

METHODS

34 LOS and 235 EOS completed the Positive and Negative Syndrome Scale, the Psychotic Symptom Rating Scales, and the Beck Depression and Anxiety inventories. Subgroups experiencing delusions were compared matching for chronological age and gender, and also when matched for chronicity and gender.

RESULTS

Delusions were very common at over 80% in both groups. LOS participants with delusions exhibited greater suspiciousness/paranoia, greater belief-conviction, and reduced insight when compared with the EOS group. These findings remained when matching for chronicity of illness, but disappeared when matching for chronological age. Hallucinations were surprisingly rarer in LOS (35%) than EOS (57%), with half the LOS group reporting whispers rather than clearly audible sounds. In general, anxiety, depression, and distress were as marked in LOS and EOS.

CONCLUSIONS

Similarities between EOS and LOS far outweighed the differences across a range of symptoms and measures. Greater delusional conviction, paranoia, and poorer insight in LOS were associated with the later age of onset rather than relating to chronicity of illness. As belief-conviction in LOS was not associated with increased grandiosity, disorientation, or unusualness of thought content, as it was in EOS, delusional conviction may be determined somewhat differently later in life.

Risk factors for the late-onset psychoses: a systematic review of cohort studies

BACKGROUND

Psychoses with onset in late adulthood are challenging. Identifying those older patients at risk would be clinically important and would have research implications.

METHODS

A computer search was performed to identify all cohort studies of risk factor(s) for psychotic symptoms or disorders with onset at 40 years or older. Experts were contacted and bibliographies were screened for additional references. Validity of located studies was assessed according to evidence-based medicine criteria for risk factors studies. Data were extracted and tabulated for qualitative and quantitative analyses.

RESULTS

Twelve articles were retrieved, corresponding to 11 studies of 32 potential risk factors. In the qualitative analysis, only the history of psychotic symptoms, cognitive problems, poor health status, visual impairment, and negative life events appeared to be significant risk factors of late-onset psychosis. Older age, female gender, and hearing impairment were not associated with psychosis in older patients. Quantitative analysis was feasible with only one item, female gender, and confirmed the lack of associated risk with late-onset psychosis.

CONCLUSIONS

Despite the methodological limitations of the studies included in this review, there is some evidence from cohort studies that history of psychotic symptoms, cognitive problems, poor physical health, visual impairment, and negative life events are risk factors for late-onset psychosis. More long-term follow-up studies are needed to confirm these findings.

'Not of this world': the subjective experience of late-onset psychosis

OBJECTIVES

Psychosis with first onset after the age of 60 arising in the absence of dementia or primary affective disorder is thought to affect 2-4% of older people. Up to half will not respond fully to medication.The subjective experience of living with late-onset psychosis (LOP) has not yet been considered and this study represents a preliminary attempt to explore the subjective experience and psychological features of older people living with LOP.

METHOD

The study was conducted in Ireland. Seven participants between the ages of 67 and 87 years who met diagnostic criteria for very late-onset schizophrenia-like psychosis were interviewed using a semi-structured interview schedule. Participants spoke about previous life experiences as well as the experience of developing and living with LOP. Interpretative phenomenological analysis was used to identify common themes within their accounts.

RESULTS

Four themes emerged which reflected participants' subjective experiences of earlier life stages as well as their current experiences of LOP. Three interrelated themes described participants' experiences of social isolation, a solitary coping style and the experience of the self as 'different'. A final theme reflected participants' attempts to explain and find meaning in their psychotic experiences.

CONCLUSIONS

Results support the view that the experience of LOP emerges in the context of psychosocial vulnerabilities combined with adversities associated with the experience of ageing.

Psychotic symptoms and paranoid ideation in a population-based sample of 95-year-olds

OBJECTIVE

To examine the 1-year prevalence of psychotic symptoms and schizophrenia in nondemented 95-year-olds, and to examine the relation between psychotic symptoms and other psychiatric symptoms, sensory impairments, and cognitive functioning.

PARTICIPANTS

The representative sample was 95-year-olds living in Göteborg, Sweden (N = 338). Individuals with dementia were excluded (N = 175), leaving 163 subjects for this study.

DESIGN

This was a cross-sectional population study, including psychiatric and physical examinations, cognitive tests, and interviews with close informants.

MEASUREMENTS

Diagnosis of schizophrenia, psychotic symptoms, paranoid ideation and dementia according to Diagnostic and Statistical Manual of Mental Disorders, Third Revision (DSM-III) were measured. Cognitive function was tested with the Mini-Mental State Exam. Other psychiatric symptoms were measured by the Comprehensive Psychopathological Rating Scale.

RESULTS

The one-year prevalence of any psychotic symptom was 7.4% (95% confidence interval [CI] 3.8-12.5); including hallucinations 6.7% (95% CI 3.4-11.8) and delusions 0.6% (95% CI 0.0-3.4). Four (2.4%) individuals fulfilled DSM-III-R criteria for schizophrenia. Individuals with psychotic symptoms or paranoid ideation did not differ regarding cognitive functioning compared with individuals without these symptoms. Individuals with hallucinations and paranoid ideation had an increased frequency of previous paranoid personality traits compared with individuals without psychotic symptoms and paranoid ideation. No individuals with psychotic symptoms had a formal thought disorder, incoherence of speech, or flat affect.

CONCLUSION

The authors found a high prevalence of psychotic symptoms, paranoid ideation, and schizophrenia in the very old. Most of the symptoms were elucidated by information from key informants, illustrating the importance of including relatives in the evaluation of elderly persons.

Schizophrénie tardive ou délires chroniques

HISTORICAL ASPECTS

Chronic delusion occurring late in life has essentially been studied by European psychiatrists. "Late-onset schizophrenia" was first described and defined by Manfred Bleuler in 1943, as a form of schizophrenia which occurs after the age of 40. Later, British psychiatrists often used the term "Late-onset paraphrenia" interchangeably with "Late-onset schizophrenia" to designate this disorder. However, late-onset paraphrenia is a British concept which includes all delusional disorders starting after age 60. American psychiatrists had little interest in this patient group, so it is only within the DSM III-R that a separate category was created for patients who developed schizophrenia after age 44. There is now no longer a "late-onset" category for schizophrenia within the DSM IV, nor age criterion for the diagnosis of schizophrenia. In the French nosography, schizophrenia is excluded when a non-affective, non-organic psychosis begins after the age of 40. These chronic delusion syndromes fall into a specific French category: "Psychose Hallucinatoire Chronique" (chronic hallucinatory psychosis).

LITERATURE FINDINGS

Basing themselves on the analysis of many studies, the authors endeavor to define the characteristics of late-onset schizophrenia. The exact prevalence is not known, but is considered lower than 1%. There is a preponderance of women over men in this form of disease, that could be explained by the relative excess of dopamine type 2 (D2) receptors in young men (compared with young women), and by a protective role played by estrogens until the menopause, among women predisposed to schizophrenia. Studies of families reveal a lower lifetime risk of schizophrenia in first degree relatives of patients with late-onset schizophrenia, than those with an early onset. Most of these patients have been or are married, and had worked for a long time. Generally at the onset of the illness they are isolated and unemployed. Paranoid and schizoid abnormal premorbid personality traits are frequently noted with the diagnosis of late-onset schizophrenia. An association between late-onset schizophrenia and sensory impairment (visual and auditory) is frequently observed and appear to be in link with auditory and visual hallucinations. The analysis of clinical features reveal that the later the schizophrenia breaks out, the more the patient shows delusion and hallucinatory symptoms, which remain limited to his surroundings, whereas in younger patients, delusion has no limit. Moreover, late-onset schizophrenic patients have a lower prevalence of looseness of associations and negative symptoms than those with an earlier onset. The authors note from the few studies on the treatment, that a number of patients responded well to low dose of antipsychotic agents. The use of "atypical" anti-psychotic drugs is recommended, in order to reduce the adverse effects, notably the extrapyramidal symptoms which are frequent in elderly people.

CONCLUSION

Finally, they conclude that patients with late-onset schizophrenia have symptoms very similar to those of patients with early-onset schizophrenia. But, when taking the different forms of schizophrenia - even the late onset ones - into account, raises the question of the role of trigger factors that could guide research on predictive factors and early diagnosis. This may be one explanation for the survival of the French entity "Psychose Hallucinatoire Chonique".

Psychological processes underlying delusional thinking in late-onset psychosis: a preliminary investigation

BACKGROUND AND AIMS

It has been suggested that delusions may serve as a defence against negative self-representations. The present study investigated general psychological well-being and evidence for defensive emotional processes among people with late-onset psychosis.

METHOD

The performance and responses of older people with late-onset psychosis (n = 13), older people with depression (n = 15), and age-matched healthy controls (n = 15) were compared in a cross-sectional design. Participants rated their own levels of depression and self-esteem, and completed an emotional Stroop task to establish whether there was evidence of implicit depression in the absence of explicit acknowledgement. Participants rated themselves on a number of personal attributes in relation to two life stages to generate discrepancies in 'actual', 'ideal' and 'other' self-concepts, and completed measures of their perceptions of current and past psychological well-being.

RESULTS

People with late-onset psychosis showed no evidence of overt depression or low-self esteem. All three groups showed an attentional bias to depression-related and age-related words, although response times overall were faster for controls. The psychosis group showed no discrepancies between either their past or their current 'actual' and 'other' self-concepts, suggesting that they do not have more negative views about how others see them.

CONCLUSIONS

Evidence from this study does not support the application of the 'delusion-as-defence' model to late-onset psychosis, but methodological constraints must be borne in mind when interpreting the findings.

Onset of Schizophrenia at Age 100

Schizophrenia is generally regarded as a disease starting in adolescence and early adulthood. Cases beginning after the age of 60 are rare. The authors present the case of a woman who, at the age of 100, developed an illness marked by delusions and hallucinations and who was diagnosed with schizophrenia, paranoid type. Authors discuss the differential diagnosis of psychotic symptoms presenting late in life.

Older people with schizophrenia: a community study in a rural catchment area

BACKGROUND

An increasing number of older people with schizophrenia are living in the community but we still have little data on their clinical presentation, service use and functioning.

METHODS

All patients over the age of 60 years with a primary diagnosis of a non-affective psychotic disorder who were known to health services were identified in a rural area of East England. Subjects were interviewed with the Present State Examination and other standardised interview instruments.

RESULTS

Seventy-two subjects fulfilled study inclusion criteria. Forty-six of these had first become ill before the age of 60 years and 26 after (the very late onset group (VLO)). Eighty per cent were women and 26% had never married. Eighty-seven per cent lived in their own homes and 51% alone. In the preceding month, 41% of the sample had experienced psychotic symptoms and 15% depressive symptoms. Twenty-seven per cent of the sample were cognitively impaired. The earlier onset group had significantly higher rates of tardive dyskinesia and negative symptoms of schizophrenia and were treated with higher doses of neuroleptics. The VLO group had higher rates of hearing impairment (54% vs 15% p = 0.001) and of partial or no insight (93% vs 55% p = 0.004).

CONCLUSIONS

Despite significant differences in presentation, elderly patients with schizophrenia and very late onset schizophrenia-like psychosis have much in common. Both groups are vulnerable with high levels of psychopathology, poor insight, sensory impairment and social isolation. The needs of older people with schizophrenia must be taken into account when services for older adults are planned.

CAG nucleotide repeat profiles in persons with schizophrenia or schizoaffective disorders with and without tardive dyskinesia: pilot study

Tardive dyskinesia (TD) is a drug-induced syndrome of involuntary movements often associated with neuroleptic treatment of psychiatric conditions. Huntington's disease (HD) and other neurological conditions are caused by CAG nucleotide repeat expansions in specific genes. We, therefore, explore the hypothesis that TD may be related to CAG repeat expansion by using the repeat expansion detection (RED) method as a measure of CAG content without knowledge of the location of the responsible gene. The number of CAG repeats ([CAG](n)) from persons with schizophrenia or schizoaffective disorders with (n = 10) and without (n = 9) TD are determined. A comparison of [CAG](n) in persons with (56.90 +/- 23.45 repeats) and without (57.00 +/- 19.35 repeats) TD was not statistically different. The total [CAG](n) was determined by combining [CAG](n) for both groups. The median of 45 repeats was used to divide the total into two groups (SG1 and SG2 with smaller and larger [CAG](n) fragments, respectively) and a means analysis of the two subgroups based on [CAG](n) demonstrated that SG1 (n = 10 samples at 45 repeats per sample, mean [CAG](n) = 45.00 +/- 0.00) was significantly smaller than SG2 (n = 9, ranging from 48 to 120 repeats, mean = 70.22 +/- 24.83; P < 0.005). Thus, this lends support to the idea of CAG repeat expansions in the study population. Results are encouraging that a larger population and a more structured subject selection process may yield more meaningful information about the relationship between CAG repeat expansion and TD.

Long-acting injectable antipsychotics in the elderly: guidelines for effective use

The elderly are at increased risk for psychosis because of age-related deterioration of cortical areas and neurochemical changes, comorbid physical illnesses, social isolation, sensory deficits and polypharmacy. The prevalence of psychiatric and neuropsychiatric disorders requiring treatment with an antipsychotic agent is expected to increase dramatically among people aged >64 years. Antipsychotic agents are effective in the treatment of schizophrenia, schizoaffective disorder, behavioural symptoms in patients with dementia, and mood disorders with psychosis. However, failure to adhere to a prescribed medication regimen by patients with psychosis is one of the most frustrating problems faced by mental healthcare providers, because of the high risk of relapse associated with partial compliance. For patients with psychosis who will not or cannot take oral medications on a regular daily basis or have other characteristics, such as memory, vision or auditory impairment, which contribute to partial compliance, long-acting injectable antipsychotic medication offers a solution. Older patients are especially at risk of adverse effects associated with traditional antipsychotic agents, such as motor effects, postural hypotension, excessive sedation, and anticholinergic effects because of age-related pharmacokinetic and pharmacodynamic factors, coexisting medical illnesses and concomitant medications. Therefore, drug dosage recommendations in the elderly are much more conservative than in younger patients. The appropriate starting dose of an antipsychotic in older individuals is 25% of the usual adult dose; total daily maintenance doses ranges from 25-50% of the adult dose. There are few studies regarding the use of depot antipsychotics in elderly patients. Studies that are available indicate that traditional antipsychotic agents given as depot injections are associated with positive outcomes in the elderly. Because the risks for extrapyramidal symptoms and tardive dyskinesia are reduced dramatically with atypical antipsychotics compared with traditional agents, the development of long-acting atypical antipsychotic formulations has been pursued. Of the atypical antipsychotics, risperidone is the first agent to be approved in a long-acting injectable formulation. Unpublished clinical data have revealed that patients treated with long-acting injectable risperidone (25mg, 50mg or 75mg) are more likely to show significant clinical improvement than placebo. In addition, hospitalisation rates decreased continuously and significantly during 1 year of treatment for patients who received long-acting injectable risperidone.Long-acting injectable antipsychotic medication should be considered for older patients for whom long-term treatment is indicated. The choice of which drug to use should be based on patients' history of response and personal preference, clinician's previous experience and pharmacokinetic properties.

Clinical characteristics and length of hospital stay among older adults with bipolar disorder, schizophrenia or schizoaffective disorder, depression, and dementia

Although many older adults with serious psychiatric illnesses share common concerns, such as medical comorbidity, personal loss, greater propensity for adverse medication effects, and greater dependence on others for basic needs such as transportation, individualized treatment needs must be differentiated by underlying psychiatric disorders. This retrospective study evaluated clinical characteristics and resource use among 137 older adults with bipolar disorder, schizophrenia or schizoaffective disorder, depression, and dementia who were discharged from an urban, academic medical center's inpatient geropsychiatric unit. The authors found women to be significantly overrepresented among individuals with schizophrenia or schizoaffective disorder compared to those with bipolar disorder, depression, and dementia (P=.034). Among those with bipolar disorder, anticonvulsant medications were predominantly used as mood stabilizers, with only the rare use of lithium. Individuals with schizophrenia or schizoaffective disorder were the youngest group of patients; individuals with dementia were the oldest group (P<.001). This shows significant differences in clinical characteristics among hospitalized older adults with serious mental illnesses. Additional studies are needed on outcomes of serious chronic psychiatric illnesses in later life to optimize care environments for older adult psychiatric patients.

Hallucinations: synchronisation of thalamocortical gamma oscillations underconstrained by sensory input

What we perceive is the product of an intrinsic process and not part of external physical reality. This notion is consistent with the philosophical position of transcendental idealism but also agrees with physiological findings on the thalamocortical system. gamma-Frequency rhythms of discharge activity from thalamic and cortical neurons are facilitated by cholinergic arousal and resonate in thalamocortical networks, thereby transiently forming assemblies of coherent gamma oscillations under constraints of sensory input and prefrontal attentional mechanisms. Perception and conscious experience may be based on such assemblies and sensory input to thalamic nuclei plays merely a constraining role in their formation. In schizophrenia, the ability of sensory input to modulate self-organisation of thalamocortical gamma activity may be generally reduced. If during arousal thalamocortical self-organisation is underconstrained by sensory input, then attentional mechanisms alone may determine the content of perception and hallucinations may arise.

Gender related differences in clinical characteristics and hospital based resource utilization among older adults with schizophrenia

OBJECTIVE

This report is an analysis of gender related differences in clinical characteristics and hospital based health resource utilization among older adults with schizophrenia and schizoaffective disorder in an acute care, state hospital over a one-year period.

METHODS

This retrospective record review is an analysis of age of illness onset, psychiatric and medical comorbidity, hospital utilization, and psychotropic medication use.

RESULTS

There were a total of 66 individuals with either schizophrenia or schizoaffective disorder. Mean age of this group was 55.2 +/- 4.62 years. Women were significantly over-represented among individuals with late onset schizophrenia and schizoaffective disorder. Men with schizophrenia had more comorbid substance abuse compared to women with schizophrenia (p < 0.05). Women and men did not differ significantly in hospital length of stay, amount or type of antipsychotic medication prescribed, or in utilization of seclusion/restraint in hospital. Both genders had substantial utilization of antipsychotic medication. Use of conventional antipsychotic medication monotherapy was always associated with use of anti-extrapyramidal symptom (anti-EPS) medication, while use of atypical antipsychotic medication monotherapy was more rarely associated with use of anti-EPS medication.

CONCLUSIONS

In later life, women and men may have some areas of differing health care needs. Women in particular may benefit from psychoeducational approaches that address the experience of psychiatric illness of relatively recent onset (for example, symptom identification and acceptance of illness). Men may benefit from particular emphasis on treatment of comorbid substance abuse disorders.

The French concept of "psychose hallucinatoire chronique" -a preliminary form of schizophrenia? The role of late-life psychosis in the anticipation hypothesis of schizophrenia

The distinction between schizophrenia and chronic delusional syndromes (including the French concept of “psychose hallucinatoire chronique” [PHC] or chronic psychotic hallucinations, paraphrenia, and late paraphrenia) is currently used in various European countries, although there are no international criteria for chronic and bizarre delusions. The French concept of PHC is characterized by late-onset psychosis, predominantly in females, with rich and frequent hallucinations, but almost no dissociative features or negative symptoms. PHC and late-onset schizophrenia may have risk factors in common, which may help differentiate these disorders from young-onset schizophrenia, especially with regard to the potential role of (i) the estradiol hypothesis; (ii) the impact of sensory deficit; (Hi) putative specific brain abnormalities; or (iv) specific genetic mutations. In accordance with this hypothesis, and taking into account the familial aggregation analyses of PHC, here we evaluate the possibility that PHC represents a less severe form of schizophrenia, which would partly explain the “Sherman paradox” also observed in schizophrenia. The Sherman paradox describes the fact that multiplex families frequently have only one affected ascendant, meaning that an isolated sporadic case is at the origin of a highly loaded family. We thus propose that if unstable mutations are involved in the risk for schizophrenia, then PHC might represent a moderate disorder belonging to the schizophrenia spectrum phenotype.

Paranoid ideation among elderly African American persons

PURPOSE

The prevalence and correlates of paranoid ideation were investigated.

DESIGN AND METHODS

On the basis of a sample of 998 independently living elderly African American persons in a cross-sectional study, the study used the Brief Symptom Inventory to measure paranoid ideation and 14 independent variables, including demographic characteristics, cognitive deficit, depression, self-reported memory functioning, emotional and instrumental support, stressful life events, limitation of daily activities, self-rated health status, and self-rated hearing and vision.

RESULTS AND IMPLICATIONS

Paranoid ideation (symptoms of paranoia) was found in 10% of this sample. A multiple regression analysis of the data revealed that of the 14 independent variables used in this study, 6 (income, instrumental support, hearing, stressful life events, self-reported memory deficit, and depression) showed a significant relationship with paranoid ideation.

Stapes surgery and psychiatric complications

Changes in auditory perception can cause disturbances in development and personality. This phenomenon has been studied in particular in children hearing loss or in progressive or sudden hearing loss in the adult. We present the case of a patient with psychobehavioural alterations after restoration of hearing following a small fenestra stapedectomy for bilateral otosclerosis with moderate-severe hearing impairment. The diagnosis, physiopathology and medicolegal implications are discussed.

Quantitative study of signal hyperintensities on T2-weighted magnetic resonance imaging in late-onset schizophrenia

OBJECTIVE

The authors investigated the extent and distribution of signal hyperintensities on T2-weighted magnetic resonance imaging (MRI) of the brains of subjects with late-onset schizophrenia.

METHOD

The study group consisted of 25 subjects with DSM-III-R schizophrenia and onset at age 50 or more years (late-onset schizophrenia) matched group-wise with 24 subjects with early-onset schizophrenia and 30 psychiatrically healthy volunteers. The subjects underwent clinical and neuropsychological assessments and MRI scans. Transaxial T2-weighted and proton-density images were analyzed manually for signal hyperintensities in cerebral and cerebellar white matter, the basal ganglia, thalamus, and brainstem, and quantitative measures were obtained.

RESULTS

Subjects with late-onset schizophrenia had greater periventricular hyperintensities measured as widths of periventricular rims and frontal and occipital caps than the two comparison groups. Hyperintense signals elsewhere in the white matter and in the basal ganglia and brainstem did not differ between groups, but the late-onset schizophrenia group had more signal hyperintensities in the thalamus than the normal comparison group. Signal hyperintensities in the frontal-subcortical circuit regions, when considered together, did not differ between groups. Periventricular hyperintensities had significant negative correlations with intelligence, memory, and frontal-executive functioning in the total group.

CONCLUSIONS

The finding of increased periventricular hyperintensities and thalamic signal hyperintensities in late-onset schizophrenia suggests the possibility that cerebrovascular disease, in an interaction with some incompletely understood vulnerability factors, may play a role in the pathogenesis of schizophrenia with onset in advanced age.

A descriptive study of first presentation psychosis in old age

OBJECTIVE

This report describes the characteristics of a sample of elderly subjects presenting with their first episode of psychosis in old age.

METHOD

Forty-six (38 females and eight males) patients were assessed on a variety of cognitive, psychopathological and personality measures.

RESULTS

Female preponderance, social isolation and early cognitive deficits were findings of this study which have been replicated by other studies of late-onset psychosis. In contrast, hearing loss was not overly represented in this sample. Personality style differed significantly from accepted norms of adult personality traits, with lower scores for dimensional ratings of neuroticism, extraversion and openness to change.

CONCLUSIONS

The descriptive findings in this study suggest that psychosocial factors require further investigation in patients presenting with late-onset psychosis. Comparison with younger first-onset psychotic subjects will be the subject of a later report.

Schizophrenia with onset after age 50 years. 2: Neurological, neuropsychological and MRI investigation

BACKGROUND

Late-onset schizophrenia (LOS) may have a basis in age-related coarse brain disease, but empirical support for this is conflicting.

AIMS

Is LOS characterised by more neurological disease than early-onset schizophrenia (EOS)?

METHODS

DSM-III-R-defined LOS subjects (n = 27) were compared with 30 EOS and 34 volunteer control subjects on neurological status, neuropsychological test performance and brain magnetic resonance imaging (MRI).

RESULTS

LOS and EOS groups had more 'soft' neurological signs and drug-induced movement abnormalities, and performed more poorly on tests assessing speed of information processing, memory and frontal executive functioning. On MRI, the LOS and EOS groups had greater lateral ventricular size than the control group. The LOS subjects also had more signal hyperintensities in periventricular white matter and subcortical nuclei than controls.

CONCLUSIONS

LOS and EOS subjects were very similar on neuropsychological, neurological and structural neuroimaging parameters, except that there were more MRI periventricular hyperintensities in LOS subjects.

Late paraphrenia: a variant of schizophrenia manifest in late life or an organic clinical syndrome? A review of recent evidence

A large amount of research has been devoted during the past 15 years to the clinical and neurobiological aspects of the disorder named as 'late paraphrenia' (LP) in 1955. The symptomatology and diagnosis of the disorder, its prognosis, the cognitive functioning of those affected, the structural changes in the brain as revealed by modern techniques of brain imaging and its postmortem neuropathology have all been submitted to investigation. The results have been widely regarded as consistent with the concept of LP as an organic disease of the brain, but increased knowledge of the neurobiology of schizophrenia and of the age-related changes that occur in the brains of elderly people casts doubt on the validity of this interpretation. The findings are consistent with the view that LP is the form in which schizophrenia is manifest in old age. The proposal that LP has a closer kinship with affective disorder than with schizophrenia is part of a general theory of the sex differences in schizophrenia. In LP it becomes entangled with the organicity hypothesis, suggesting that neither of these explanations is adequate, and most of the evidence points to a unitary concept which views LP as a variant of a single disorder, namely schizophrenia, which, however, requires a broad definition. This concept has implications for fresh paths of enquiry.

Clinical case discussion: the elderly patient with psychosis

OBJECTIVE

To present a clinical case of an elderly person with psychosis and to discuss associated diagnostic and treatment issues.

METHODS

A case from 1 of the authors' clinical practices was presented in English and French to several groups of Canadian psychiatrists attending a teaching day on psychosis. Three geriatric psychiatrists acted as facilitators, soliciting the clinical experiences of the participants in the discussion. The authors integrated clinical content from these sessions with results of a Medline search on psychosis in elderly persons.

RESULTS

The assessment of elderly patients with psychosis is more often than in younger patients by overlying organicity, including delirium due to illness or medication use, dementia, or sensory deficits. Treatment might further worsen cognitive, affective, and functional impairment through adverse effects such as extrapyramidal symptoms (leading to decreased mobility and general functioning), anticholinergic effects (predisposing to delirium), and hypotension (predisposing to falls). Newer antipsychotics with less hazardous side effect profiles have an increasing role, but they must be coupled with psychosocial support to maximize the patient's independent functioning and quality of life after discharge.

CONCLUSIONS

Assessment and treatment of the elderly person with psychosis must consider a wide variety of biopsychosocial variables, seeking to minimize further treatment-related deterioration. Controlled studies of antipsychotics in elderly people must be conducted in a variety of diagnostic situations that reflect their actual use in the community, and information must be propagated effectively among general psychiatrists, family physicians, and geriatric psychiatrists. The role of nonpharmacologic interventions in elderly persons with psychosis is even less well understood and deservers further study.

Epidemiology of paranoid symptoms in an elderly population

BACKGROUND

Elderly people with paranoid symptoms are a taxing group for medical and social services, but studies of the prevalence of these symptoms in the general elderly population are rare. This study aimed to estimate the community prevalence and to identify some associated variables.

METHOD

A community samples of 1420 elderly people, was extensively examined by nurses and physicians.

RESULTS

Paranoid ideation was found in 6.3% of the sample. The prevalence in people with cognitive dysfunction (n = 381, 12.1%) was higher than in those without (n = 1039, 2.6%). Once cognitive impairment had been controlled the associated variables were: being divorced, being female, having depressive symptoms, using psychotropic drugs, having no friends or visitors, using community care and being an immigrant.

CONCLUSION

Paranoid symptoms in this elderly population were associated most strongly with cognitive impairment. Other associated variables pointed to a higher level of social isolation than others in the community.

Therapeutic targets in late-life psychoses: review of concepts and critical issues

Psychoses in late life are a diagnostic challenge because of disagreement over how these entities should be classified. The main diagnostic categories of late-life psychoses include dementia with psychotic symptoms, late-onset schizophrenia, delusional disorder, early-onset psychotic disorders extending through late life, late-onset mood disorders, psychotic disorders caused by medical conditions or medications, and delirium. First onset of psychotic symptoms in late life is commonly associated with identifiable structural brain abnormalities and reflects underlying brain pathology. We reviewed the available literature on late-life psychotic manifestations, focusing on diagnostic classification and treatment approaches. Antipsychotics are the mainstay of treatment for these conditions, but should be used cautiously in elderly patients because of their increased sensitivity to side effects. Overall, appropriate research data on the effectiveness of various antipsychotic agents for late-life psychotic conditions are lacking. Non-antipsychotic psychotropic medications may be of value in managing some of these conditions.

Regional cerebral blood flow in late-onset schizophrenia: a SPECT study using 99mTc-HMPAO

Functional neuroimaging studies have been performed in many young patients with schizophrenia, but late-onset schizophrenia (LOS) remains largely unexamined by these techniques. We predicted that LOS would demonstrate regional cerebral blood flow (rCBF) abnormalities similar to those seen in early-onset schizophrenia (EOS), but with a basis in demonstrable coarse brain disease. The subjects were 15 LOS and 7 EOS patients and 27 healthy controls. Each was given a detailed clinical and neuropsychological assessment and underwent MRI and Tc99m-HMPAO single photon emission computed tomography (SPECT) scans. The LOS subjects had a significantly lower cerebral hemispheric perfusion than controls, with a lower perfusion in the frontal and temporal lobes bilaterally. The LOS group also had significantly lower left-to-right hemisphere blood flow ratios. EOS subjects had a lower frontal perfusion than the controls, which was significant in the left frontal region. The temporal perfusion in the EOS subjects was greater than in the LOS group, and not different from the control subjects. Left temporal perfusion was the most discriminating variable between LOS and control subjects on logistic regression. Correlations of perfusion with MRI were generally low with the exception that the asymmetry indices were significantly correlated, and basal ganglia perfusion correlated with basal ganglia hyperintensities on MRI. The total cerebral perfusion index correlated significantly with the mini-mental state examination (MMSE) score, and the temporal lobe perfusion correlated with MMSE scores and some verbal memory measures. In the schizophrenic groups, perfusion correlated nonsignificantly with symptom profiles. We conclude that our findings of temporal and frontal rCBF abnormalities, especially on the left side, in LOS are similar to those reported in schizophrenia in general. The results do not provide evidence for coarse brain disease underlying the rCBF abnormalities in LOS, or support the specificity of these abnormalities for particular subsyndromes of schizophrenia.

The case for a psychological perspective on late-onset psychosis

OBJECTIVE

A conceptual framework is proposed for studying late-onset psychotic disorders. This incorporates developmental and psychological perspectives to complement the biological focus of most recent studies in this area.

METHOD

Studies of late-onset psychosis that focus on the specificity of neuroimaging abnormalities, family history and sensory deficits were reviewed. Aspects of the developmental and personality literature were then examined with the goal of ascertaining their relevance for the emergence of psychosis in late life. Possible future directions incorporating biological and psychological approaches are proposed.

RESULTS

The biological abnormalities identified in studies of late-onset psychosis lack the specificity to stand alone as aetiological factors. Neuroimaging changes and sensory impairment are commonly found in study subjects; however, they also occur in elderly persons without psychiatric illness as well as in those with other late-onset psychiatric disorders. Perhaps it is more appropriate to regard these changes as conferring a vulnerability to psychosis in old age, but symptoms do not develop unless other risk factors, either longstanding or ageing-related, are also present. Developmental studies of late life that have used Erikson's concept of a final lifestage crisis of achieving 'ego-integrity', suggest that personality style may be influential in determining the negotiation of this last maturational task. Failure to do so results in 'despair', fragmentation of self-image and paranoid fears. To date, there has been little investigation of the relevance of these developmental and personality factors for the emergence of psychosis in old age.

CONCLUSIONS

If we are to advance our understanding of late-onset psychotic disorders, research in this area needs to move beyond the elusive search for specific biological markers. A model of causation that integrates the longitudinal perspective of lifestage tasks with personality and biological vulnerability factors provides a broad framework which protects against premature foreclosure on aetiological determinants.

The epidemiology of functional psychoses of late onset

For the functional psychoses of late life, epidemiological information comes from two sources: studies of persons who have reached psychiatric services; and surveys of elderly persons sampled from the general population. A conspectus of published data from both sources leads to the following conclusions: States phenomenologically similar to those found in clinics do occur in the community in non-trivial numbers. There is no notable divergence in the information obtained from clinical series and from population-based surveys. These states are more common in women, they become more common with increasing age and are sometimes associated with decline in cognitive performance or with degenerative changes in the brain revealed by neuroimaging. Genetic factors appear to be less important than in early-onset psychoses but remain ill-defined, and the roles of social isolation and disorders of personality have not yet been sufficiently elucidated. Both clinical and community-based studies have found an association with sensory impairment. The community-based data suggest that paranoid symptoms may be detectable at subclinical level, and an association between them and cognitive impairment is demonstrable in individuals who are not diagnosable cases either of psychosis or of dementia. Differences exist between late-onset paranoid psychoses and affective psychoses in symptomatology and response to treatment. These observations confirm the importance of the late-onset psychoses for research directed towards uncovering the origins of psychotic symptoms in any age group.

Management of dementia-related behavioral disturbances: a nonpharmacologic approach

OBJECTIVE

To describe practical nonpharmacologic approaches to dementia-related behavioral problems for enhancement of the function and care of elderly patients with dementia.

DESIGN

We reviewed the pertinent medical literature and summarized strategies and available resources for management of geriatric patients with dementia and behavior problems.

RESULTS

For optimal care of older patients with dementia, key concepts of related behavior problems must be understood. Agitation and aggression, resisting help with care, wandering, incontinence, sleep disturbance, and emotional lability can become difficult management issues with such patients. In some patients, these disruptions can lead to overmedication and nursing home placement. Herein, practical nonpharmacologic measures for management of behavior problems that arise among community-dwelling and institutionalized elderly patients with dementia are discussed. Attention is directed to the medical, psychologic, environmental, and social factors that may contribute to unwanted behaviors.

CONCLUSION

Nonpharmacologic approaches can help ameliorate behavioral problems and assist in the overall care of elderly patients with dementia.