Late-Life Psychosis

Late-life psychosis is a very common, very serious psychiatric disorder of the elderly. It is characterized by loss of contact with reality and often includes hallucinations and/or delusions. Late-life psychoses include both late-onset schizophrenia and, more commonly, early-onset schizophrenia in people who have survived into old age. Late-life psychoses also include delusional disorder, psychosis in patients with dementia or depression, and miscellaneous psychoses.

Late-life psychosis is one of the most common conditions, with a lifetime risk of 23%. With the elderly population increasing at a rapid rate, the prevalence of late-life psychosis is expected to increase dramatically. Nevertheless, late-life psychosis has not been well-studied.

Most elderly people with schizophrenia had onset of the disorder in their late teens or early twenties. Although the prevalence of schizophrenia in younger adults is 1%, high rates of cardiovascular disease in people with schizophrenia significantly reduce their life expectancy. As a result, late-life schizophrenia is relatively uncommon with an estimated prevalence of 0.3%. However, symptoms of late-life psychosis are very common in neuropsychiatric conditions and affect about 40% of people with Alzheimer's disease and other dementias. It has been suggested that late-onset psychosis in people with dementia is more common after age 60.

People with late-life schizophrenia and other late-life psychoses have high rates of other medical conditions, especially metabolic and cardiovascular diseases. These conditions are often worsened by poor healthcare, poor diet, smoking, substance use, lack of physical exercise, and psychotropic medications, especially atypical antipsychotics, as well as physiological changes that affect people with schizophrenia.

There are many different causes of late-life psychosis, since any disorder than affects the brain can lead to psychotic symptoms. For about 60% of patients with newly diagnosed late-life psychosis, the psychosis is secondary to another physiologic disorder. Acute— sometimes reversible—causes of late-life psychosis include delirium, alcohol and/or other substance use or withdrawal, and certain neurological diseases. Common chronic causes of late-life psychosis include:

Primary and secondary late-life psychoses cannot be distinguished by their symptoms. However, organic psychosis caused by known physical damage to the brain or a brain disease usually causes more visual hallucinations. Psychosis associated with dementia or delirium usually has more cognitive symptoms.

According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a diagnosis of schizophrenia requires one month of at least two of the following symptoms within a six-month period of overall functional disturbance:

Interestingly, some patients with late-life psychosis display new and unexpected artistic talents as their psychotic symptoms worsen. These can be similar to talents observed in some autistic savants. It has been suggested that as areas of the brain are destroyed by neurodegenerative disease, areas associated with creativity, which were previously suppressed, can begin to emerge.

KEY TERMS

Atypical antipsychotics—
Second-generation antipsychotics; drugs used to treat schizophrenia and other psychoses. Atypical antipsychotics do not usually cause the same degree of movement side effects as typical or first-generation antipsychotics.
Delirium—
A disturbance of consciousness marked by confusion, inattention, delusions, hallucinations, and agitation; distinguishable from dementia by its relatively sudden onset and variation in the severity of symptoms.
Delusional disorder—
A type of psychosis in which a person cannot distinguish between what is real and what is imagined.
Delusions—
Persistent false beliefs held in the face of strong contradictory evidence.
Dementia—
A group of symptoms (syndrome) associated with a chronic progressive impairment of memory, reasoning ability, and other intellectual functions, personality changes, deterioration in personal grooming, and disorientation.
Hallucinations—
False sensory perceptions; hearing sounds or seeing people or objects that are not there; hallucinations can also affect the senses of smell, touch, and taste.
Schizophrenia—
A psychotic disorder characterized by loss of contact with one's environment, deterioration of everyday functioning, and personality disintegration.

Because so many different conditions can cause late-life psychosis, diagnosis usually requires various tests, including:

Baseline assessments and follow-up physical exams and laboratory tests are important for preventing additional problems caused by treatment with antipsychotic drugs. These can include weight gain, diabetes, and cardiovascular problems, among other side effects.

Treatment and management of late-life psychosis depend on the cause of the psychosis and other medical conditions that are affecting the patient. However, there is very little evidence-based information on treatments for late-life psychosis. Environmental and psychosocial interventions are often the first-line treatment. These include functional adaptation skills training and cognitive-behavioral social skills training that can help with functioning and managing symptoms. Low-dose atypical (second-generation) antipsychotic medications, such as clozapine or risperidone, are often used. However, these drugs are associated with a higher risk of stroke and death in patients with dementia, and they require careful monitoring with physical and neurologic exams, electrocardiography, and laboratory tests. In general, for dementia-associated psychosis, low doses of atypical antipsychotic medications are used for short periods and discontinued whenever possible.

See also Delusions; Dementia ; Schizophrenia .

Resources

BOOKS

Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Arlington, VA: American Psychiatric Association, 2013.

Solai, LalithKumar K. “Late-Life Psychosis.” In Geriatric Psychiatry, edited by Mark D. Miller and LalithKumar K. Solai. New York: Oxford University, 2013.

PERIODICALS

Al Jurdi, Rayan K., Soham Rej, and Martha Sajatovic. “Aging with Serious Mental Illness: An Overview and Implications for Service Delivery.” Generations 38, no. 3 (Fall 2014): 14–22.

Iglewicz, Alana, Thomas W. Meeks, and Dilip V. Jeste. “New Wine in Old Bottle: Late-life Psychosis.” Psychi-atric Clinics of North America 34, no. 2 (June 2011): 295–318. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3093110 (accessed August 28, 2015).

Köhler, Sebastian, and Barton W. Palmer. “New Perspectives on Late-Life Psychosis.” American Journal of Geriatric Psychiatry 21, no. 2 (February 2013): 97–9. http://www.ajgponline.org/article/S1064-7481(12)00065-6/abstract (accessed August 28, 2015).

Nebhinani, N., V. Pareek, and S. Grover. “Late-Life Psychosis: An Overview.” Journal of Geriatric Mental Health 1, no. 2 (2014): 60–70. http://www.jgmh.org/article.asp?issn=2348-9995;year=2014;volume=1;issue=2;spage=60;epage=70;aulast=Nebhinani (accessed August 28, 2015).

Piore, Adam.“The Genius Within.” Popular Science 282, no. 3 (March 2013): 46–53.

Reinhardt, Michael M., and Carl I. Cohen. “Late-Life Psychosis: Diagnosis and Treatment.” Current Psychiatry Reports 17, no. 1 (2015). http://link.springer.com/article/10.1007%2Fs11920-014-0542-0 (accessed August 28, 2016).

WEBSITES

American Geriatrics Society. “A Guide to the Management of Psychotic Disorders and Neuropsychiatric Symptoms of Dementia in Older Adults.” Advancing Excellence in America's Nursing Homes. April 2011. https://www.nhqualitycampaign.org/files/AGS_Guidelines_for_Telligen.pdf (accessed August 28, 2015).

ORGANIZATIONS

American Geriatrics Society, 40 Fulton St., 18th Fl., New York, NY, 10038, 1(212) 308-1414, Fax: (212) 8328646, info.amger@americangeriatrics.org, http://www.americangeriatrics.org .

American Psychiatric Association, 1000 Wilson Blvd., Ste. 1825, Arlington, VA, 22209, (703) 907-7300, (888) 35PSYCH (357-7924), apa@psych.org, http://www.psychiatry.org .