Psychosis in the Elderly:an Approach to Persecutory

Beliefs6th October 2010

Dr. Jonathan Crowson

Learning Objectives

• Define psychosis, paranoia and persecutory beliefs

• Understand physical and organic causes of psychosis

• Understand how schizophrenia is different in patients over 65

• Be aware of pitfalls in managing psychosis in seniors

Contents

• What do the terms mean?• Experimental ideas about how

psychosis may originate• Types of psychotic illness in the

elderly and their causes• Illustrative case vignettes• A bit about antipsychotic drugs

What is Psychosis?

• Depends who you ask and when you ask them

• Term 1st used in 1845• From greek “psyche” = soul / mind +

“osis” = abnormal state of

Working definition

“An abnormal mental state in which there is a loss or distortion of contact with reality”

Often with hallucinations, delusions and disorganised thinking

What is Paranoia?

• From greek again, meaning self referential

• Originally used by Emil Kraepelin in pure paranoia

• Today almost always used to denote a belief in being persecuted unjustified by the evidence

Common Persecutory Beliefs -1

Common Persecutory Beliefs -2

Persecutory Beliefs – keeping up with the Joneses (or Bin Ladens)

The Tickle Experiment

Invented a machine to give a standardised tickle

The Tickle Experiment

Invented a machine to give a standardised tickle

People who don’t have schizophrenia cannot be tickled by themselves

The Tickle Experiment

Invented a machine to give a standardised tickle

People who don’t have schizophrenia cannot tickle themselves

People with schizophrenia can be tickled by themselves as well as by others

Model of Self Awareness

Thought or action is planned

Model of Self Awareness

Thought or action is planned

Conscious memory created

Thought or action is

processed in separate brain

area

Model of Self Awareness

Thought or action is planned

Conscious memory created

Record of creating the thought or

action created

Thought or action is

processed in separate brain

area

Subsequent recall is attached to the record of

ownership

Illnesses and persecutory beliefs

Functional V Organic

Illnesses and persecutory beliefs Functional:

Paranoid personality disorderSchizoaffective disorderDelusional disorderSchizophreniaParaphrenia

Affective disorders

Delusional disorders

• Delusions are encapsulated• Daily functioning is not affected• Other psychotic features are not

present

Schizophrenia in later life

Defect state / “burnt out”Positive symptoms of hallucinations

and delusions less prominentNegative symptoms of apathy, lack of

socialisation, lack of emotionality more prominent

More prone to side effects of medications

65 Today

The Golden Years

Unhealthy lifestyle

Increased vascular risk

Dementia and depression

Cognition and Schizophrenia

Cognitive changes are a normal part of schizophrenia.

Cognition and Schizophrenia

Typically episodic memory is preserved but working memory and verbal memory are affected

Visuospatial tasks are often sparedSequencing is impairedOverall processing is slowerAttention is impaired during psychosis

The case of Mr. V. - 1

67 y.o. man referred from schizophrenia service as “dementing”

Hx of paranoid schizophrenia for 45 years

Still actively psychotic with positive symptoms

Cognition in mildly impaired range

The case of Mr. V. - 2

Psychosis slowly settledCognition now in normal rangeCT brain shows several small infarcts but

no atrophyDischarged to supported livingNot demented but risk in future from CT

1 year later further infarcts and clinically apparent mild dementia

Enlarged Ventricles in Schizophrenia

Paraphrenia

Doesn’t exist in DSM / ICD any more

People who have delusional systems that interfere with everyday life but have preservation of interpersonal , social skills, personality and intellect

Often late onset but not necessarily

The case of Mr. D - 1

60 y.o. Man, 1st presentation to psychiatry

Working as an accountantHad friends and girlfriend though

never marriedLikeable, easy going guyNo illicit drugs, no prescribed drugsGood physical health

The case of Mr. D - 2

Became terrified of being killed by CIASpent a night in a graveyard to avoid

capture and deathDelusions of reference about people in

carsSelf presented to police to complain

about events

The case of Mr. D - 3

No hallucinationsNo thought disorderNo cognitive impairmentEmotional response in keeping with his

beliefsNormal physical investigations

The case of Mr. D - 4

He doesn’t have enough symptoms or duration of illness to have schizophrenia

He was too ‘caught up’ in his delusions to have delusional disorder

Paraphrenia ‘fits’ him better than either

Illnesses and persecutory beliefs Organic:

DeliriumDrug inducedDementia associatedMedical disorders – • Multiple sclerosis, Parkinson’s disease,

Sarcoidosis, Sjogrens’ disease, Systemic lupus erythematosus, Rheumatoid arthritis, encephalitis, encephalopathy, Hashimotos’s disease

Psychosis in Dementia

Common, usually paranoidUnder recognisedCauses distress to patientsLeads to behavioural disturbanceMay be the first symptom of the illness

Sorting It Out - History

Any psychiatric illness or medical condition

SubstancesOther physical complaintsDetailed description of delusionsOther psychotic symptomsTiming, onset, progression

Sorting It Out - Investigations

Full examination + vital signsBlood work – CBC, urea, lytes,

creatinine, liver and thyroid function, calcium

Urinalysis and cultureCXR, ECGCT brain+/- EEG

Treatment

Make a diagnosisFind and correct any underlying

cause(s)Antipsychotics are the mainstay of

symptom controlConsider cognitive impairmentConsider mood disorderTry reducing meds after period of

stability

Using Antipsychotic Drugs

Start low, go slowWatch for accumulationBeware postural BP changes and cardiac

conductionThey all cause EPSE except quetiapine +

clozapineNo difference in terms of efficacy except

clozapine (it’s better)I tend to reduce dose or switch drug rather

than use anticholinergics

My tips on antipsychotic drugs

If any depressive features – quetiapine or olanzapine

Avoid olanzapine in people with diabetes

Depots WITH CAUTION either flupenthixol decanoate or Risperidal Consta

For less sedation Stelazine or haloperidol

If not responding by half full dose unlikely to respond to higher dose.

Thank you for Listening

Any Questions?