Functional Mental Illness in Later Life: Psychosis

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Functional Mental Illness in Later Life Psychosis

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

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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)

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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

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Negative symptoms

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

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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

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Alcoholic Hallucinosis

• History of excessive alcohol intake
• 2nd person auditory hallucinations most common
• Persecutory ideas/ideas of reference
• co-morbid depressive symptoms
• cognitive impairment

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Onset after 60 non-organic, non-affective Late-ons
et schizophrenia Late life psychosis
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Schizophrenia
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Classification and Incidence

• Late-onset schizophrenia (LOS)
• - illness onset gt 40 yrs
• -12.6 per 100 000 population per year
• Very-late-onset schizophrenia-like psychosis
  (SLP)
• - illness onset gt 60 yrs
• - 17-24 per 100 000 population (Holden et al,
  1987)

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Criteria for SLP

• Onset gt 60 years
• Presence of fantastic, persecutory, referential,
  or grandiose delusions /- hallucinations
• Absence of primary affective disorder
• MMSE gt24/30
• No clouding of consciousness
• No history of neurological illness/alcohol
  dependence
• Normal blood chemistry
• (see Howard et al, 2000)

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

• Formal thought disorder
• Negative symptoms

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Plus some extra symptoms.

• Complex visual hallucinations
• Partition delusions

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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
  (lt5) and may represent misdiagnosed cases

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Partition Delusions

• Watched /overheard through partition 40
• Human intruder to home -theft 34
• Non-human intrusion gas/radiation 30
• Somatic effect of intrusion
• 20

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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.
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SLP Cognitive Outcome

• 25 ? cognitive impairment consistent with a
  diagnosis of dementia within 3 years
  
• (Holden 1987, Reeves 2001)
• 75 stable cognitive deficits

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Risk Factors for SLP

• Age incidence ? by 11 for every 5 yr ? in age
  beyond 60 years
• Female Gender 4 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

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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)

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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

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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

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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

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When to Intervene..

• 3 reasons to intervene When symptoms are
  causing
• distress to the point where the person is at risk
  of
• Self-harm
• Self-neglect
• 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.