Functional Mental Illness in Later Life:

Psychosis

Neil Robertson

Slides adapted from Dr Suzanne Reeves, Senior Clinical Lecturer, IOP.

Psychosis

Psychosis is an umbrella term for a number of psychotic illnesses that include:

Drug induced psychosis

Organic psychosis

Bi-polar disorder

Schizophrenia

Psychotic depression

Schizo-affective disorder

(Taken from EPPIC)

Psychosis is characterised by:

Hallucinations – sensory perceptions in the absence of external stimuli – Types?

Delusions – a belief held with strong conviction despite evidence to the contrary

Formal Thought Disorder - presenting with incomprehensible thought patterns and/or language

Catatonia - state of neuro-genic motor immobility, and behavioural abnormality manifested by stupor, over-activity or rigidity

Negative symptoms

Blunted affect Poverty of speech Anhedonia Lack of desire to form relationships Lack of motivation

Psychotic Depression

Prevalence ~2% -35% of older inpatients

- 5% of young adults Delusions - persecutory, hypochondriacal, poverty Hallucinations - 2nd person auditory, olfactory, gustatory Co-morbidity - physical co-morbidity in older

compared to young adult patients

Alcoholic Hallucinosis

History of excessive alcohol intake 2nd person auditory hallucinations most common Persecutory ideas/ideas of reference

~ co-morbid depressive symptoms

~ cognitive impairment

Onset after 60 non-organic, non-affectiveOnset after 60 non-organic, non-affectiveLate-onset schizophreniaLate-onset schizophreniaLate life psychosisLate life psychosis

Schizophrenia

Classification and Incidence

Late-onset schizophrenia (LOS)

- illness onset > 40 yrs

-12.6 per 100 000 population per year

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

- illness onset > 60 yrs - 17-24 per 100 000 population (Holden et al, 1987)

Criteria for SLP

Onset > 60 years Presence of fantastic, persecutory, referential, or

grandiose delusions +/- hallucinations Absence of primary affective disorder MMSE >24/30 No clouding of consciousness No history of neurological illness/alcohol dependence Normal blood chemistry

(see Howard et al, 2000)

People with SLP have all the symptoms of schizophrenia except for...

Formal thought disorder

Negative symptoms

Plus some extra symptoms….

Complex visual hallucinations

Partition delusions

Phenomenology of SLP

Non-verbal auditory hallucinations 70% 3rd person auditory hallucinations 50% Hallucinations in other modalities 30% Delusions -

persecution 85%

reference 75% misidentification 60%

partition 70% Formal thought disorder, negative symptoms rare

(<5%) and may represent misdiagnosed cases

Partition Delusions

Watched /overheard through partition 40%

Human intruder to home +-theft 34%

Non-human intrusion – gas/radiation 30%

Somatic effect of intrusion 20%

Howard, R et al (1992). Int J Geriatr Psychiatry 7; 719-724

PERMEABLE WALLS, FLOORS, CEILINGS AND DOORS. PARTITION DELUSIONS IN LATE PARAPHRENIA

A partition delusion is the belief that people, objects or radiation can pass through what would normally constitute a barrier to such passage. These delusions have been reported to be common in late paraphrenia and late-onset schizophrenia. Such partition delusions were found in 68% of 50 patients with late paraphrenia, but only in 13% of patients with schizophrenia who had grown old and in 20% of young schizophrenics.

SLP: SLP: Cognitive Cognitive OutcomeOutcome

25% cognitive impairment consistent with a diagnosis of dementia within 3 years

(Holden 1987, Reeves 2001(Holden 1987, Reeves 2001))

75% stable cognitive deficits

Risk Factors for SLP Age:Age: incidence incidence by by 11% for every 5 y11% for every 5 yr r in age beyond 60 years in age beyond 60 years

Female Gender: 4 4 x higher risk compared to men x higher risk compared to men - not explained by higher proportion of ‘older’ women - ?loss of protective effect of oestrogen post menopause

Sensory Deficits : Auditory 40%, Visual 20%

Genetic Factors: more likely to have a FH of affective disorder

Pre-morbid Personality: paranoid, depressive, anxious or schizoid traits

Social Cognition Deficits Deficits in social cognition reported in young adults

with schizophrenia Believed to represent a reduced ability to process

context-based information People with SLP report similar deficits in ‘executive

function’ as young people with schizophrenia Social processing - mentalising (understanding the

intentions of others) - also affected in SLP (Moore et al, 2006)

Other possible risk factors for SLP

As yet unidentified biological factor vulnerability towards SLP

Genetic loading for affective disorder Female sex Increasing age Migrant status Unmarried state and isolation Specific deficits in social cognition

Treatment of SLP

Summary:

Pharmacological: No RCTs but observational studies suggest that low dose antipsychotic medication is effective

Psychosocial: Observational studies suggest that engagement with a keyworker and increasing positive social interactions may improve outcome

Psychosocial aspects of treatment

Aim to increase positive social interactions

- Correcting sensory deficits may reduce the risk of misinterpretation of others’

- Increase social outlets,encourage attendance at hospital/luncheon club

- Allocating a keyworker/care co-ordinator to facilitate this and to monitor mental state

When to Intervene..

3 reasons to intervene: When symptoms are causing

distress to the point where the person is at risk of

(i) Self-harm

(ii) Self-neglect

(iii) Retaliation against the ‘perpetrator’

When not to intervene:

When the person is refusing treatment AND the risks are

low in terms of self or others.