Transcript psychotic disorders in elderly persons

PSYCHOTIC DISORDERS IN
ELDERLY PERSONS
Carl I. Cohen, M.D.,
SUNY Distinguished Service Professor,
Professor & Director, Division of Geriatric
Psychiatry,
SUNY Downstate Medical Center
Brooklyn, NY
email: [email protected]
No Disclosures
Two Preliminary Points
In older adults, for all conditions:
think “Comorbidity”
For any new psychiatric
conditions or change in
symptoms:
Must assume physical cause
until proven otherwise
Definition of Psychosis
1st used in 1845: “psychosis” (soul/mind) + “osis”
(abnormal state of)
Presence of “hallucinations
and/or delusions”
Key Points:
1.Can be primary (due to
psychiatric disorder) or secondary
(due to medical/neurological
disorder)
Key Points (continued)
2.There are no reliable
pathognomonic signs to
distinguish primary or secondary
psychosis (dx of exclusion: need to
rule out secondary causes).
Thus, every new onset psychoses or
notable change in symptoms needs
a medical work-up.
A) Primary psychotic disorders:
Schizophrenia and related disorders
Schizophrenia
Schizoaffective disorder
Schizophreniform disorder
Delusional disorder
Brief psychotic disorder
Affective psychoses
Bipolar disorder with psychotic features
Unipolar depression with psychotic
features
B) Secondary psychotic disorders:
• Psychotic symptoms associated with dementia
Alzheimer’s Disease with psychoses
Vascular dementia with psychoses
Lewy Body Disease with psychoses
Other dementing disorders with psychoses
• Psychotic symptoms during delirium (“toxic
psychoses”)
• Psychotic symptoms associated with
medications and substance abuse
• Psychotic symptoms due to medical and
surgical disorders
Freudenreich, 2010
Lifetime Risk
(1 in 4 lifetime risk)
Up to 23% of the older adult
population will experience
psychotic symptoms at some
time, with dementia being the
main contributing cause
(Khouzam & Emes, 2007).
Prevalence of Psychosis in Elderly Persons
• Community: 0.2% to 4.7%;
In NYC study (Cohen et al, 2004): 3% psychosis (7%
Blacks vs 2% Whites), but if include paranoid ideation:
14 % of sample.
• Age 85+ (without dementia): 7.1% to 13.7%. May be
prodromal for dementia
Age 95+(without dementia): 7.4%
• Nursing Homes: 10% to 62%
• Geriatric Psychiatry In-Patient Units: 10% late onset
psychosis--¾ are women, 40% due to AD or VaD
Etiologies of Psychoses in Older
Adults
(order of frequency)
1. Alzheimer’s disease and other dementias (40%)
2. Depressive disorder (33%)
3. Medical/toxic causes including substances (11%)
4. Delirium (7%)
5. Bipolar Affective Disorder (5%)
6. Delusional disorder (2%)
7. Schizophrenia spectrum disorders (1%)
Manepalli et al, 2007 and Webster et al, 1998
Risk Factors for Psychoses in Older Adults
1.
2.
3.
4.
5.
6.
Sensory deficits
Social isolation
Cognitive decline
Medical comorbities
Polypharmacy
Age related changes in pharmacokinetics and
pharmacodynamics
7. Comorbid psychiatric illnesses such as dementia and
delirium
8. Age-related changes in cerebral structures such as
frontotemporal cortices
9. Neurochemical changes associated with aging
Psychoses may be multifactorial and occurs in the context of frailty, limited reserve
capacity, increased vulnerability to stressors.
Delirium
1. Perceptual disturbances are common; however,
hallucinations also are frequent:
• Hallucinations: 40% to 67%
• Delusions: 25% to 50%
• Psychotic symptoms are more commonly seen
with hyperactive rather than hypoactive delirium
• Visual > > auditory> other hallucinations
• Paranoid delusions are the most common
delusions
• Clinical evaluation should help identify; dementia
and delirium are often related
Dementia
Alzheimer’s Disease
• Prevalence of psychotic symptoms: 16% to 70%;
Median: 37% for delusions; 4% to 76% (Median 23%)
for hallucinations
• Rates of psychoses: about 20% in early stages to 50% by
third or fourth years of illness (Overall: 30% to 50%).
• Most common in middle stages.
• Hallucinations: visual> auditory> other.
• Hallucinations most commonly people from past, e.g.,
deceased relatives, intruders, animals, objects.
• Delusions: most common are false beliefs of theft,
infidelity of one’s spouse, abandonment, house not one’s
home, and persecution. Decreases in later stages.
•
Different from misidentification
syndromes which may be more
cognitively- related: Capgras Syndrome
(imposters), Phantom Boarder
Syndrome(guest in house); Mirror Sign
(mistakes self in mirror for someone
else, TV or Magazine Sign (believes
people on TV or in magazine are real).
7. Some evidence that psychotic
symptoms are associated with a more
rapid decline.
8. Need to rule out underlying medical
problems and visual difficulties
9. Jeste & Finkel(2000) proposed
classification of “Psychoses in AD” as
presence of hallucinations and/or
delusions of at least one month
duration, even if intermittent, serious
enough to disrupt life of patient or
others, and patient meets criteria for AD,
not explainable by delirium, drug effects,
schizophrenia or other psychiatric
disorders.
Vascular Dementia
Cache County study found prevalence of
hallucinations similar between AD and
VaD, but delusions were higher in AD
(23% vs 8%).
Lewy Body Dementia
• About half have visual hallucinations (up to 80%
in some studies), and it’s an early sign in 43%.
1.Auditory hallucinations (20%) and paranoid
delusions(65%) are also common
2.Some texts say psychotic symptoms are more
common than in AD.
3. Recent studies have reported 29% to 50% rate of
misidentification syndromes such as Capgras
syndrome or Phantom Boarder Syndrome (about
twice rate of AD patients)
Parkinson’s disease
• Overall rates: 20 to 60% --- about ¼ have hallucinations
in PD, but ¾ have hallucinations with Parkinson’s
Disease with Dementia (PDD). Thus, psychosis is more
common in later stages of PD.
• Hallucinations much more common than delusions.
• PD without cognitive decline:
(a) No medication: psychotic sx may occur but rare.
(b) On medication: minor psychotic sx, with or without
insight may occur (10-20%) such as:
• visual illusions(distorted perceptions)
• benign visual hallucinations/sense presence
(someone is nearby when there is no one)
• passage hallucinations (fleeting imagery in peripheral
vision)
• PD and Dementia: often experience psychotic
symptoms in the absence of medications;
dopaminergic therapies may trigger or
exacerbate symptoms
(75% prevalence of psychosis in this category)
• REMEMBER:
Extrinsic causes > Intrinsic causes, i.e.,
hallucinations in PD most commonly secondary
to dopaminergic agents(extrinsic). Need to
assess onset of symptoms. Medications produce
vivid visual hallucinations.
Affective Psychoses
Unipolar Depression
1. Psychotic depression occurs in 20% to 45% of
hospitalized elderly depressed patients; 15-25%
•
•
•
of community depressed persons.
Delusions are more commonly moodcongruent, including delusions of guilt,
delusions of deserved punishment for
moral or personal inadequacies, delusions
of nihilism, somatic delusions, delusions of
poverty.
Auditory hallucinations are less common
and not easily described, such as vague
derogatory voices.
Catatonia in severe depressive episodes
Bipolar Illness
• Psychotic symptoms occur in context of manic
or depressive episodes.
• Bipolar depression is similar to unipolar
depression with respect to predominantly
mood-congruent delusions.
• Bipolar mania also presents with
predominantly mood-congruent delusions such
as grandiosity, erotomania, delusions about
possessing special powers.
Substance Induced Psychosis
•
•
•
•
•
Prevalence of substance use disorders in elderly persons:
2%-3% in women and 10% in men.
Psychotic symptoms may occur during alcohol (e.g., DTs),
sedative, or barbiturate withdrawal, whereas stimulants
(amphetamines, cocaine, OTC weight –reducing drugs)
can cause symptoms with intoxication.
Opiates such as narcotic analgesics, heroin, codeine, and
methadone may induce delirium, and consequently,
psychoses
Prescribed medications. Most common causes of psychosis
are the “anti’s”:anti-inflammatories (inc steroids),
antiparkinsonian drugs, anticholinergic drugs,
antiarrhythmic agents, antivirals, antibiotics, antimalarials.
If tactile hallucinations occur, consider drug withdrawal
states, toxic, or metabolic disturbances.
Medical Illness
• Medical illnesses can cause psychosis with and
without delirium.
• DSM criteria require prominent hallucinations or
delusions, with evidence from the history, physical
examination, or laboratory findings that the
disturbance is physiological consequence of the
general medical condition. It should not be better
accounted for by another mental disorder and does
not occur exclusively during the course of a
delirium.
• Typical medical causes of psychosis are neurological,
infectious, metabolic, and endocrine.
• Elderly persons are more at-risk because of high rates
of physical illness, polypharmacy, and susceptibility to
disruption of brain function.
Table 1. Common Medical Causes of Psychosis in
Older Persons
Metabolic
Infections
Vitamin B12 or folate
deficiency, electrolyte
abnormalities
Meningitis, encephalitis(e.g.,
herpes), syphilis, HIV/AIDS
Neurological
Parkinson’s disease, epilepsy,
subdural hematoma, stroke,
Huntington’s disease (rare),
tumor(rare)
Endocrine
Thyroid disease, adrenal
disease, hyper- or
hypoglycemia
Adapted from Desai and Grossberg, 2003
Sorting Out Medical Causes of
Psychoses from Non-Medical Causes
• Medical causes are often characterized
by paranoid delusions, persecutory
thoughts, and ideas of reference.
• May resemble paranoid schizophrenia
but delusions are usually more concrete,
non-bizarre, and changeable.
• Paranoid schizophrenia is usually more
abstract, bizarre, and unchanging.
Pies, 2008
Schizophrenia
Early-Onset Schizophrenia
Schizophrenia typically develops in the second or third
decade of life, but greater numbers of schizophrenia
patients are surviving into old age.
• Between 80-85% of persons aged 55 and over
developed schizophrenia before age 45.
Prevalence estimates for schizophrenia in
adults aged between 45 and 60 are
approximately 0.6% to 1%.
• There will be a doubling of the number of persons aged
55 and over with schizophrenia, from about 550,000 in
2005 to 1.1 million in 2025. By that time, about onefourth of persons with schizophrenia will be in this older
age bracket.
There is heterogeneity in outcome in
schizophrenia into later life.
Long-term studies observing the symptoms and
functioning in early-onset schizophrenia suggest
that the course of schizophrenia may not be as
pessimistic as previously thought, and such
findings challenge the notion implied in the
term dementia praecox.
Based on long-term studies carried out in Europe
ranging from 22 to 37 years, Ciompi found:
*20 to 27% of patients attained complete
symptomatic remission,
*22 to 33% attained mild end states,
*24% to 29% attained intermediate end-states,
*14 to 18% attained severe end-states.
Thus, roughly half of persons exhibited recovery
or mild end-states, and half showed moderate or
severe end states.
1. Outcome from earlier life (depends on definitions):
About half improve in psychopathology, one-third remain
unchanged, and about 15% get worse.
Textbook: (Jeste et al APPI Textbook of Geriatric
Psychiatry,2004): 20% remission in positive and negative
symptoms; 60% largely unchanged; 20% worsening of
symptoms.
2. “Social recovery” was observed in about half of
subjects.
3. Looking at a more comprehensive definition of recovery,
Auslander and Jeste found only 8% of older outpatients
attained “sustained remission,” based on symptom remission,
social functioning, and medication dosage.
4. Better prognosis: female, later development of illness, better
premorbid functioning, married, acute-remitting course.
Not Generally a Progressive
Disorder
Community-dwelling older persons with
schizophrenia (about 85% this population)
have been generally found to have a nonprogressive course. The non-progressive
course suggests schizophrenia is a static
encephalopathy rather than a dementing
disorder.
Public Policy Issues
Remission is Not Typically
Stable (“quiescent”) in Later
Life (so called “end –stage”)
On 4 ½ year follow-up:
One-quarter of older persons
with schizophrenia remain in
remission;
One-third never attain
remission;
Two-fifths fluctuate between
states.
(Cohen et al, AAGP annual meeting, 2012)
Suggests need for more intense
interventions in later life
Based on
community crosssectional data
Based on
hospital
data
2. Increasingly, there is a more nuanced approach to
outcome. There are outcome measures based on
symptoms (e.g., positive symptoms, negative
symptoms, cognition, depression) and global
parameters (e.g. remission, community integration,
quality of life, social adaptive functioning) that are
only weakly associated with each other (4% shared
variance).
Thus,
Each outcome category may require separate
interventions rather than a single intervention that
impacts on all outcome measures.
Late-Onset Schizophrenia
A review of studies of late-onset schizophrenia
found that approximately 23% of patients with
schizophrenia were reported to have
experienced the onset of the disorder after age
40, with 13% in the fifth decade of life, 7% in
the sixth decade, and 3% in later decades.
Roughly 15% onset over age 44, but a study
in the UK found 29% with onset after age 44.
“Late paraphrenia” used by Martin
Roth in 1950s(UK) to describe persons
with no family history who developed a
schizophrenia like illness (hallucinations
and delusions) after age 65. Term has
been used in various ways. In ICD 9 it
referred to delusional disorder in later
life; similar to DSM II. Not in DSM-IVTR or ICD10.
Demarcation
The International Late-Onset Schizophrenia Group has
proposed that schizophrenia with an onset between age
40 and 60 be termed “Late-Onset Schizophrenia” and
be considered a subtype of schizophrenia.
The authors believe that schizophrenia with onset in
middle age is a neurodevelopmental disorder, and that
differences with early-onset schizophrenia are more of
degree than of kind.
No differences between early and late onset groups in:
positive symptoms, family history, brain abnormalities,
memory retention, or minor physical abnormalities.
The late-onset group is more likely to:
1. Be female versus no gender differences in early-onset,
2. Have the paranoid subtype of schizophrenia,
3. Have lower levels of negative symptoms,
4. Have less impairment in learning, abstraction, and
flexibility,
5. Better premorbid functioning with respect to work
and marriage.
The International Late-Onset Group also proposed the
term, “Very Late Onset Schizophrenia-Like
Psychosis” for disorders that begins after age 60. This
disorder has features that suggest a neurodegenerative
component including more brain abnormalities and
neuropsychological deficits.
This disorder is also distinguished from the other
two types by:
1. many more females;
2. greater prevalence of persecutory and partition
delusions;
3. higher rates of visual, tactile and olfactory
hallucinations;
4. lower genetic load;
5. more sensory abnormalities;
6. absence of negative symptoms or formal thought
disorder.
Schizoaffective Disorder (DSM-5)
Must have uninterrupted period of illness in which
symptoms meet Criterion A for schizophrenia and a
major mood episode (depression or mania). During
this episode there must have been delusions or
hallucinations for at least 2 weeks in the absence of
major mood sx. Symptoms of major mood disorder
must be present for majority(“substantial” in DSM
IV-TR) of the active & residual phase of illness.
Critique: A shifting (unstable) and irrational dx:
a. Differs between episodes;
b. How can having both depression and
schizophrenia turn into a 3rd disorder?
Schizoaffective Disorder (cont.)
• Research suggests that schizoaffective
disorder may be subcategory of
schizophrenia or psychotic depression
because they share epidemiology, clinical,
and neuropsychological features.
• High prevalence of depressive symptoms
in schizophrenia--11% to 75% depending
on the level of severity-- make diagnosis
more problematic.
Delusional Disorder
1.Delusional
disorder
is
differentiated
from
schizophrenia by a lack of prominent auditory or
visual hallucinations (and if present, related to
delusional theme), and an absence of deterioration
in areas of functioning outside the delusional scope.
-Distinguished from dementia by absence of cognitive
impairment.
-Distinguished from mood disorder by delusions
preceding any mood disturbances.
2.The delusions are non-bizarre and involve situations
that may occur in real life, such as theft, suffering from
a disease, spousal infidelity, or being followed.
3. Delusional disorder difficult to differentiate from the
paranoid schizophrenia, but the latter has more bizarre
delusions and auditory hallucinations. Poor psychosocial
functioning in delusional disorder is directly related to the
delusional beliefs.
4. Prevalence:0.03%
5. Risk factors: Persons with schizotypal or paranoid
personality disorders; mixed findings regarding
association with hearing loss.
6. MRI findings had no significant differences from
normals.
7. The course of delusional disorder may vary but tends to
be chronic, especially in those with the persecutory type
of delusional disorder.
6 “Ds” of Psychiatric Diagnoses in Older
Adults that Co-Occur with Psychoses
Think of these possibilities and consider
course:
• Delirium: days to weeks
• Drugs: days to months
• Disease: days to months
• Depression: weeks to months
• Dementia: months to years
• Delusional disorder and schizophrenia:
months to decades
Growing
Importance
Freudenreich, 2010
Treatment
Early-Onset Schizophrenia
• Lack of control studies, e.g., CATIE trial from ages 18
to 65.
• Recent federal warnings about increased mortality risk
in elderly dementia patients adds to the concern
regarding use of antipsychotic medications.
• An expert review panel recommended risperidone
(1.25–3.5 mg/day) as the first line of treatment.
Quetiapine (100–300 mg/day), olanzapine (7.5–15
mg/day), and aripiprazole (15–30 mg/day) were
viewed as good second-line treatments. Starting
dosages for late-onset persons at 25% of the
recommended adult dose and maintenance doses
at 25-50% of the adult dose. Often, effective doses
for early-onset can be 50-75% of younger patients.
There has been only one large-scale
randomized, double-blind controlled trial
comparing atypical antipsychotics—
risperidone(1mg to 3mg/day, median dose
2mg/day) and olanzapine(5mg to 20mg/day,
median dose 10mg/day)-- in adults older than
60. Positive symptoms, negative symptoms,
disorganized thoughts, and symptoms of
anxiety/depression improved significantly
from baseline in both groups. There were no
significant differences in side effects except
for more clinically significant weight gain in
the olanzapine group.
Risk of developing tardive dyskinesia with conventional
antipsychotic medications: 29% (after 1year –nearly 6x
that of younger persons), 50% (2 years), 63% (3 years).
Rates substantially lower with atypical antipsychotic
medications (5% after one year).
Other side effects: EPS and anticholinergic effects are
higher in elderly persons.
Novel Psychosocial Interventions
in Schizophrenia
Various neurocognitive and social cognitive abilities
are targeted such as :
•Neurocognition(e.g., working memory: storage &
manipulation of information for learning; cognitive
flexibility: ability to shift sets )
•Social Cognition & Perception
•Verbal Communication
•Social Skills
•Interpersonal Problem Solving Skills
Examples with Middle-Age and Older Adults
• Integrated Psychological Therapy (IPT; Mueller et
al, 2013): cognitive remediation therapy(CRT)and
social skills therapy (SST)
• Functional Adaptation Skills Training (FAST;
Patterson et al, 2003):SST
• Helping Older People Experience Success(HOPES;
Pratt et al, 2008): SST
• Cognitive Behavioral Social Skills Training
(CBSST; Granholm et al, 2005): SST & CBT
• CRT: McGirk & Mueser, 2008; Wykes et al, 2005)
Novel Model Programs for Older
Persons with Schizophrenia
New community treatment strategies for older
adults with mental illness can be divided into:
(1) Collaborative programs: between
psychiatrists and PCPs
(2) Case management strategies: social and
cognitive skills in tandem with physical health
enhancing strategies & promoting
interdisciplinary communication .
(3) Some combination of (1) and (2).
Late-Onset Schizophrenia
a. Based on limited data, late-onset schizophrenia
patients appear to have good symptomatic
improvement with antipsychotic treatment
compared to early-onset illness individuals.
b. Substantially reduced doses of antipsychotics are
necessary in late-onset schizophrenia patients.
Maintenance therapy is frequently required,
because many of these patients relapse if they
discontinue the medication.
c. Cochrane 2013: A lack of published data
specifically examining antipsychotics in late-onset
schizophrenia (LOS), and investigations have
often mixed early- and late-onset patients. Only
one randomized trial using risperidone and
olanzapine, and both were well-tolerated, but
study had no other usable data.
d. Open studies of typical antipsychotics in LOS
indicated that 48%–61% of patients demonstrated
full remission of psychotic symptoms.
e. Cognitive behavioral therapy and social skills
training also have shown promise.
Delusional Disorders
a.
Commonly, persons deny their illness.
Consequently, non-adherence to antipsychotics is a
common problem in the treatment
b. Antipsychotic agents often are effective, especially in
agitated delusional patients. of patients with
delusional disorder.
c. For refractory cases, modified electro-convulsive
therapy has been reported as successful.
d. Cognitive-behavior therapy has been demonstrated as
an effective treatment approach.
Parkinson’s Disease
• Critical to adjust anti-parkinsonian
medication
• Quetiapine 12.5mg to 150mg has been
effective for psychotic symptoms
• Clozapine; 6.25mg to 50mg has been
effective.
• Pimavanserin(?)--a serotonin (HT2) inverse
agonist– recently successfully completed
Phase 3 trials.
Alzheimer’s Disease
CATIE study, in which time to discontinuation did
not differentiate antipsychotic medications from
placebo, and black box warnings regarding higher
mortality rates, suggests that medications must be
used judiciously. In CATIE study, the median time
to the discontinuation of treatment due to a lack of
efficacy favored olanzapine and risperidone, but
the time to the discontinuation of treatment due to
adverse events or intolerability favored placebo.
Mean doses used in CATIE trial:
risperidone(1mg), olanzepine (5.5mg) , and
quetiapine (56.5mg).
Recommended doses:
Risperidone:0.75mg to 1.5mg
Olanzepine: 2.5mg to 7.5mg
Quetiapine : 25mg to 200mg
Psychosocial modalities:
Sensory enhancement, structured
activities, social contact, behavior
therapy.
Test Yourself
Symptoms of secondary
psychoses accompany which
disorder:
1. Delusional disorder
2. Schizophrenia
3. Depression
4. Alzheimer’s disease
The most frequent cause of
psychosis in older persons is:
1. Schizophrenia
2. Alzheimer’s disease
3. Delusional disorder
4. Depressive disorder
In delirium, what is the most
common form of hallucinations in
older persons?
1. Auditory
2. Tactile
3. Visual
4. Olfactory
In Alzheimer’s disease which of
the following is true :
1. Auditory hallucinations are the most
common type of hallucination
2. Psychoses are most common in the early
stages of the disorder
3. Delusions concerning theft are common
4. Misidentification syndromes are a type of
delusion
In Parkinson’s disease which of
the following is true:
1. Extrinsic causes of hallucinations are
greater than intrinsic causes
2. Rates of hallucinations are about 10%
3. The preferred treatment for hallucinations is
risperidone
4. Rates of hallucinations are similar among
those persons with and without dementia
In depression, which of the
following is true:
1. Auditory hallucinations are common
2. Permeable wall delusion often occurs
3. Delusions are mood-congruent
4. Psychosis occurs in about 10% of
hospitalized cases
In Schizophrenia, which item is
true :
1. Approximately a quarter of early onset
cases show recovery or mild end states
2. Men develop the disorder more
commonly after age 45
3. Persecutory delusions are more
common in late onset disorders
4. Prevalence of auditory hallucinations
is similar to delusional disorder
Congratulations
You are now an expert in
Psychoses in Older Adults