Transcript here - Lambeth Resolve

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-affective
Late-onset schizophrenia
Late 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: Cognitive Outcome

25%  cognitive impairment consistent with
a diagnosis of dementia within 3 years
(Holden 1987, Reeves 2001)

75% stable cognitive deficits
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
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.