Psychosis in the Elderly

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  • By the end of this session you should be able to
  • This is how the talk will shape up.
    I’ll start by looking at what we mean by psychosis as a concept.
    I’d like to say something about some interesting ideas from experimental work about what goes wrong in the brains of people who develop psychotic disorders

    I’d then like to think a bit about some psychotic disorders in the elderly:
    Mood disorders (bipolar and depression)
    Substance induced psychosis
    Psychosis secondary to general medical condition aka organic psychosis
    Psychosis in dementia
    Schizophrenia and the paranoid states
  • So what is psychosis? Well
    The term psychosis was 1st used by Ernst von Feuchtersleben in 1845 as an alternative to insanity and mania. Up until that time all mental disorders had been lumped together as forms of mania. It had of course been recognised that some mentally ill people claimed to hear or see things that others couldn’t, for a long time. But attempts were made to devise a classification of mental disorders based on the current theories of their origins and 2 major divisions were created – Neurosis and Psychosis. Which were thought to be diseases of the nerves and the mind respectively.

    Unfortunately Psychosis has gotten a lot of bad press. Countless movies have depicted the mentally ill in general and those with psychoses in particular as dangerous killers. Populist newspapers refer to as “crazed psychotic killer[s]” people who have never suffered a days psychotic illness in their life. Schizophrenia brings images of dangerous individuals likely to fly into homicidal rage.

    In fact the truth is much more mundane. Stranger homicide is not a CSI like collection of weird ways to be murdered but being killed by someone you don’t know. This is exactly the kind of killing that the media would have us believe happens all the time at the hands of the mentally ill.
    NOT SO.
    The risk of a member of the public being killed by a mentally ill person not known to them is 1 in 14.3 million people per year for stranger homicide so about 3 per year in Canada. Compare with a 1 in 600,000 risk of being a lightning strike victim.
    The sad reality is that people with psychotic illnesses are far more likely to be assaulted by (healthy?) others than to attack anyone themselves, or be the unfortunate victim of illness driven misadventures such as Ben Silcock, an Englishman with schizophrenia who climbed into the lion enclosure at London Zoo and was mauled to death. More likely than even these is the sad fact that it is still the case that 10% of people with schizophrenia commit suicide.

    So if it’s not crazed killers, and its not any one with a mental illness what do psychiatrists mean by psychosis these days?
  • SLIDE 5
    Well this...

    But what does that mean? Contact with reality.

    Essentially that the person finds difficulty with knowing what is really happening and what is not.
    This can be obvious like someone hallucinating or it can present in more subtle ways such as delusions of reference where an unrelated event or object is given specific meaning to the individual.
    A couple of examples:
    I saw a senior lady recently who told me that she used to go school with the news caster who had just come on the television (who was about 40 years her junior) and that the news caster was giving special messages to her during the broadcasts.
    Another patient many years ago told me “when his trousers fell down I knew I was going to marry him”. That lady had an unusual delusional system that arose around a neighbour, who was a lawyer, of erotomanic fixation.

  • What about Paranoia?

    Well again we have the Greeks to thank for the origins of the word. Strictly it means self referential i.e. That a person who is paranoid believes that people or things are centred around themselves. This is the sense that Emil Kraepelin used when he coined the term PURE PARANOIA, which included disorders where there were prominent delusions with preservation of intellect and personality (to distinguish it from his DEMENTIA PRAECOX, which would eventually be renamed schizophrenia).

    So the lady with the school friends who were talking to her on TV I mentioned earlier could be regarded as paranoid, although these days we would more likely describe her as having delusions of reference.

    It is only more recently that paranoia has come to be regarded as synonymous with persecutory beliefs. Typically the sufferer will believe that others are “ out to get them” and may involve great conspiracies in this...
  • Beliefs involving aliens are common in Western countries...
  • As are beliefs about police or secret services.

    Of course these agencies DO spy on or watch people, so to regard the belief as delusional or a symptom of psychosis we need to look at the reasons for holding the belief.

    A man I saw “knew” that he was being watched by the CIA when a white van parked across the street from his house one day. He believed that they had come into his house and installed bugs which they were using to monitor his conversations and could read his thoughts.

    There are too many delusional belief systems described to go into them all today...
  • But interestingly delusional beliefs seem to keep up with the times:
    In the UK during the time of the terrorist attacks by the IRA it was not uncommon to see people whose delusional beliefs included persecution by the IRA. Such beliefs are rare in new patients now, but persecution by Al Qaeda was now being seen when I left the UK 18/12 ago.
  • Now we know what we mean by the terms psychosis, paranoid + persecutory, I’d like to share one of my favourite experiments in psychiatry with you.

    It’s called the tickle experiment and here’s what they did. (You can try this at home).

    They compared a group of people with schizophrenia with a group without mental illness. They got all the people to tickle themselves and recorded the results.

    But first of all they had to invent a way of giving a standardised tickle. Now I used to think a tickle was just a tickle but apparently not. If the tickles given to different people were different then that could ruin the experiment as any differences in outcome could be due to the different tickles. So they invented a tickling machine that gave exactly the same tickle every time you pressed a button.
  • They then got people to administer tickles to themselves using the machine. All their healthy subjects wouldn’t laugh if they were pressing the button themselves, but did laugh if someone else did the pressing for them. In other words they couldn’t tickle themselves.
  • The subjects who had schizophrenia by contrast responded equally regardless of whether it was them or some one else who was pushing the button. They could tickle themselves.

    So what conclusions did they draw?

    Well they came up with a model of how we distinguish between what we do and what the outside world does.
  • This is the model in it’s simplest form with all of the painful neuroanatomy, neurotransmitters and so on removed.

    The idea goes like this.

    We plan an action or have an idea in one part of the brain
  • In another area the thought is processed or the action actually carried out.
    But that’s not all - we can remember our thoughts and actions, often where they happened or what we were doing at the time. When we remember them we recognise them as our own. If we remember someone else’s ideas we recall the attribution as well. So when I’m up feeding our 4 month old at 3 in the morning I remember quite clearly that it was my wife’s idea (and not mine) that we have another child.
  • It seems that we do this by automatically keeping a record of not only the thought or action itself, but also of the fact that we originated it ourselves. When we process the thought or carry out the action we have that sticker attached to it that says “Home Grown” – like the strawberries in the supermarket.
    What happens if we don’t make that record of us having created the thought / action? Surprisingly it seems that we begin to make mistakes in attribution of “who said what”.

    So in the experiment they believed that the reason the people without schizophrenia couldn’t tickle themselves was that record their brains were making the record that it was them originating the action. The people with schizophrenia, the experimenters believed, could tickle themselves due to a breakdown in the registering of the action as self generated.
  • So what of the conditions in which we see persecutory beliefs and psychosis.

    Generally psychiatrists divided things up into organic causes – i.e. those which we could find a physical cause for, and functional - those we couldn’t. As time has passed we’ve learnt a bit more about the physical underpinnings of the so called functional illnesses. There are now changes detectable on brain scans in schizophrenia and depression for example, just as there are for the dementias. But the distinction still has some use.
  • The main functional illnesses that may show psychotic features are these ones listed here.

    I’ve separated the affective disorders – depression and bipolar disorder – as although they are often psychotic the ‘flavour’ of the psychotic beliefs and experiences have a mood related theme (known as mood congruent). Thus a depressed person I saw reported that the police were going to arrest him and his family. Sounds persecutory? Not really because he couldn’t find his gun licence and thought the police were going to punish him severely for this and he deserved it.

    I don’t want to say anything at all about personality disorders today.
    Much of what I say about schizophrenia could apply to schizoaffective disorder as well.
    Delusional disorders are those where a person holds unshakable beliefs without good reason to do so, but without experiencing other psychotic symptoms like hallucinations and without alteration in how organised their thoughts are

    We’ll come back to paraphrenia in a moment, but first I’d like to say a little bit about schizophrenia
  • Delusional disorders are those where a person holds unshakable beliefs without good reason to do so, but without experiencing other psychotic symptoms like hallucinations; without alteration in how organised their thoughts are and without daily functioning being disturbed other than in direct relation to the beliefs.
    Example a man had a delusional belief that his wife was being unfaithful with their neighbour. When asked how he knew this he said there were stains in her underwear that smelled of sex. He said that she smiled at the neighbour in a way that meant they were lovers. He had never

  • Schizophrenia:
    Typically people develop it in their late teens or early 20s and so by the time they get to the age group I work with, they’ve had it a long time and it can look quite different to how it did when it started out. These are some of the features of schizophrenia in people who have had the illness for many years contrasted with the typical picture in younger adults.

    There are however a number of people who develop schizophrenia in later life. The question has always been is their illness different, or are they different, from those who develop it at a younger age?
    For these purposes late = >45 and very late = >60
  • So what happens to all the people with schizophrenia and delusional disorder when they reach their 65th birthday and they go to see a geriatric psychiatrist for the 1st time?
  • Instead of looking forward to a happy retirement things work out differently.

    Initially things may not be much different. But people with schizophrenia have higher incidence of smoking and in the future will probably have a lot more metabolic syndrome if not frank diabetes. (Mainly from the drugs we will be giving them throughout their adult lives). On average they will eat less healthily

    Now we know that these things predict cardiovascular mortality and morbidity. But they are also risk factors for cognitive decline. This may be either vascular – i.e. The direct damage to the brain’s blood supply due to the atherosclerosis from being a smoker with diabetes. But also vascular risk factors are weaker risk factors for Alzheimer’s Disease.

    And as if that isn’t bad enough we’re beginning to realise that at least some of late life depression probably has a vascular element as well.
  • Cognitive impairment in schizophrenia is older than the name schizophrenia itself. Emile Kraepelin 1st described what was to become known as schizophrenia and called it Dementia Praecox.
  • So this rather busy slide is a summary of the cognitive deficits in people with schizophrenia, many of which are detectable as early as the first episode of illness. There was a study which followed a group of 8 year olds and found cognitive deficits in those who went on to develop schizophrenia when they were older


    This case illustrates some of these points...
  • An aside here on ordering CT scans as cognitive work up in older people with schizophrenia:
    Remember to tell the radiologist the person has 45 years of schizophrenia as it will help them interpret the pictures. As far back as 1978 people realised that the brain scans of people with schizophrenia were shown to look different to healthy controls with enlarged ventricles.


  • As this old image from a CT scan shows in 2 identical twins, one of whom suffered with schizophrenia. The arrows point to the lateral ventricles which are enlarged in the twin suffering schizophrenia.


  • I’d like to mention Paraphrenia. It used to be a relatively frequently made diagnosis, especially in the UK and Europe. It seems to have fallen out of favour here and been divided between schizophrenia, delusional disorder and psychotic disorder not otherwise specified. I think it is still a valuable concept, and a recent study in Quebec and New Brunswick found a modernised restating of Bleuler’s original criteria for paraphrenia was valid in a series of about 150 people with late onset psychotic disorders. The following case is illustrative of the concept...
  • This case shows a well adjusted man who became ill with a persecutory delusional system.
  • So much for the functional illnesses what of the organic?

    I don’t want to talk about delirium other than to say it’s common, often causes psychosis and behavioural disturbance, has literally hundreds of possible causes, which I won’t bore you with, and is reversible in the vast majority if the underlying cause is treated although recovery may take as long as 10 weeks.

    The list of drugs that can cause psychosis (which may include persecutory beliefs) is enough to fill several slides, and includes prescribed, herbal, illicit, alcohol. Again I don’t want to say much about that other than to highlight a couple of examples.
    Anticholinergic drugs
    Antiparkinsonian drugs
    Steroids

    The medical conditions which can cause psychosis are also too numerous to mention. In general think Rheumatic, neurological, infective, metabolic, endocrine, seizures, malignancy

    Which leaves dementia associated...
  • Estimates vary that from 25% to 40% of people with dementia have psychosis
    As AD progresses in severity, up to a third of patients suffer
    from paranoid delusions that often center on themes
    of theft as a consequence of defective memory.
    May be the presenting feature of the dementia
    CASE of Mrs. S
    Believed she could hear her son and daughter’s voices when they were at their homes many km away. Believed that they could control her and make her medicine not work by some sort of telepathy. She was suspicious her husband was being unfaithful without good reason.
    At the time of her presentation she was scoring 28/30 on MMSE. Her psychotic symptoms were relatively treatment resistant. but 2 years later she had developed a mixed Alzheimer / vascular dementia.
  • So what to do when faced with an older person with persecutory beliefs.
    1) History – previous episodes of less severe odd beliefs; family history of schizophrenia, personal history of dementia / schizophrenia.
    - other physical complaints now that may be part of an associated illness
    - List of all medications and other drugs ingested including alcohol and OTC meds
    - detailed description of the beliefs - ? Mood element, disturbance to rest of life, emotional response to symptoms
    - timing of symptoms e.g. evening (sundowning) is typical for dementia
    - other psychotic symptoms
    - evolution of the condition over time
  • 2) Investigations – to exclude delirium or medical disease causing psychosis – cbc lytes, urea, creatinine, liver and thyroid function, calcium, others as directed by physical signs / findings.
    - infection screen – urine and chest esp, swabs
    - chest x ray and ecg again looking for those medical conditions
    - brain imaging looking for cerebrovascular disease, atrophy to suggest dementia, demyelination, abscess, tumor
    May need to do further imaging e.g. MRI or EEG if seizures are a possibility or (v. rare) CJD
  • Psychosis in the Elderly

    1. 1. Psychosis in the Elderly: an Approach to Persecutory Beliefs 6th October 2010 Dr. Jonathan Crowson
    2. 2. 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
    3. 3. 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
    4. 4. 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
    5. 5. 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
    6. 6. 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
    7. 7. Common Persecutory Beliefs -1
    8. 8. Common Persecutory Beliefs -2
    9. 9. Persecutory Beliefs – keeping up with the Joneses (or Bin Ladens)
    10. 10. The Tickle Experiment Invented a machine to give a standardised tickle
    11. 11. The Tickle Experiment Invented a machine to give a standardised tickle People who don’t have schizophrenia cannot be tickled by themselves
    12. 12. 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
    13. 13. Model of Self Awareness Thought or action is planned
    14. 14. Model of Self Awareness Thought or action is planned Conscious memory created Thought or action is processed in separate brain area
    15. 15. 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
    16. 16. Illnesses and persecutory beliefs Functional V Organic
    17. 17. Illnesses and persecutory beliefs Functional: Paranoid personality disorder Schizoaffective disorder Delusional disorder Schizophrenia Paraphrenia Affective disorders
    18. 18. Delusional disorders • Delusions are encapsulated • Daily functioning is not affected • Other psychotic features are not present
    19. 19. Schizophrenia in later life Defect state / “burnt out” Positive symptoms of hallucinations and delusions less prominent Negative symptoms of apathy, lack of socialisation, lack of emotionality more prominent More prone to side effects of medications
    20. 20. 65 Today
    21. 21. The Golden Years Unhealthy lifestyle Increased vascular risk Dementia and depression
    22. 22. Cognition and Schizophrenia Cognitive changes are a normal part of schizophrenia.
    23. 23. Cognition and Schizophrenia Typically episodic memory is preserved but working memory and verbal memory are affected Visuospatial tasks are often spared Sequencing is impaired Overall processing is slower Attention is impaired during psychosis
    24. 24. 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
    25. 25. The case of Mr. V. - 2 Psychosis slowly settled Cognition now in normal range CT brain shows several small infarcts but no atrophy Discharged to supported living Not demented but risk in future from CT 1 year later further infarcts and clinically apparent mild dementia
    26. 26. Enlarged Ventricles in Schizophrenia
    27. 27. 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
    28. 28. The case of Mr. D - 1 60 y.o. Man, 1st presentation to psychiatry Working as an accountant Had friends and girlfriend though never married Likeable, easy going guy No illicit drugs, no prescribed drugs Good physical health
    29. 29. The case of Mr. D - 2 Became terrified of being killed by CIA Spent a night in a graveyard to avoid capture and death Delusions of reference about people in cars Self presented to police to complain about events
    30. 30. The case of Mr. D - 3 No hallucinations No thought disorder No cognitive impairment Emotional response in keeping with his beliefs Normal physical investigations
    31. 31. 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
    32. 32. Illnesses and persecutory beliefs Organic: Delirium Drug induced Dementia associated Medical disorders – • Multiple sclerosis, Parkinson’s disease, Sarcoidosis, Sjogrens’ disease, Systemic lupus erythematosus, Rheumatoid arthritis, encephalitis, encephalopathy, Hashimotos’s disease
    33. 33. Psychosis in Dementia Common, usually paranoid Under recognised Causes distress to patients Leads to behavioural disturbance May be the first symptom of the illness
    34. 34. Sorting It Out - History Any psychiatric illness or medical condition Substances Other physical complaints Detailed description of delusions Other psychotic symptoms Timing, onset, progression
    35. 35. Sorting It Out - Investigations Full examination + vital signs Blood work – CBC, urea, lytes, creatinine, liver and thyroid function, calcium Urinalysis and culture CXR, ECG CT brain +/- EEG
    36. 36. Treatment Make a diagnosis Find and correct any underlying cause(s) Antipsychotics are the mainstay of symptom control Consider cognitive impairment Consider mood disorder Try reducing meds after period of stability
    37. 37. Using Antipsychotic Drugs Start low, go slow Watch for accumulation Beware postural BP changes and cardiac conduction They all cause EPSE except quetiapine + clozapine No difference in terms of efficacy except clozapine (it’s better) I tend to reduce dose or switch drug rather than use anticholinergics
    38. 38. 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.
    39. 39. Thank you for Listening Any Questions?

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