Psychotic Disorders of Later Life

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Psychotic Disorders of Later Life

• Epidemiology, Classification, Treatment and
  Prognosis

2
Background

• Term paranoid still in popular use, but
  incorrectly applied
• Refers to symptoms, personality types or
  syndromes
• Can be qualitatively or quantitatively different
  from normal
• KRAEPILIN Association of paranoid symptoms with
  sensitive pre-morbid personalities (Sensitive
  Beziehungswahn- Krestchmer)
• Freud Proposed that origin was unconscious from
  defence mechanisms of denial and projection
  

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Paranoid states/Delusional disorders

• Psychotic disorders without PRIMARY mood-related,
  schizophreniform or organic basis
• Characterised by acute/chronic course with
  self-referential delusions, frequently fixed,
  elaborated and systematised
• Delusional disorder replaces paranoid state
  in ICD-10
• Derived from concept of paranoia (KAHLBAUM
  1863)
• A primary delusional system remaining unchanged
  for years
• Modern concepts of delusional disorder are
  broadly in keeping with this

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Paranoid personality disorder

• Equates with sensitive personality
• DSMIII-R defines it as
• Pervasive tendency to interpret actions of others
  as
  deliberately demeaning/threatening
• Expects to be exploited/harmed by others
• Questions loyalty of friends
• Reads threats/insults into neutral actions
• Bears grudges over altercations
• Reluctant to confide in others for fear of being
  betrayed
• Easily offended/angered by slights
• Questions fidelity of spouse/sexual partners

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Late-onset psychotic disorders

• KRAEPILIN (1912) Chronic fantastic delusions and
  hallucinations noted preservation of personality,
  lack of thought disorder and preservation of
  volition that distinguished it from schizophrenia
• Originally thought to hold an intermediate
  position between schizophrenia and paranoia
• ROTH (1955) Late paraphrenia. Well-organised
  system of paranoid delusions with/without
  auditory hallucinations with preservation of
  personality and affective response
• FISH (1960) Senile schizophrenia
• POST (1966) Persistent persecutory states of
  the elderly
• ICD-9 (1970s) Paraphrenia
• ICD-10 (1990 TO DATE) Persistent delusional
  disorder

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PROBLEMS WITH CLASSIFICATION

• Important to distinguish late-onset delusional
  disorders from people with schizophrenia who have
  become older
• American classificatory systems have used age
  cut-off as 45 compared with 60/65 in British
  systems
• Earlier classifications included mood disorder,
  personality disorder and symptoms of
  schizophrenia in definitions
• Often difficult to establish clinical picture
  such as age of onset because, by definition,
  sufferers often less amenable to interview
• Approximately 15. 7 and 5 of people with a
  lifetime history of schizophrenia will develop
  the disorder after the ages of 45, 60 and 65
  respectively

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Epidemiology

• Late-onset delusional disorders have a prevalence
  of between 2 and 4 of psychiatric disorders for
  over-65s in the community
• Incidence studies rare, but one study found
  incidence of between 17 and 26 per 100,000
• Aetiological associations encompass personality
  characteristics, genetic factors, physical
  impairment and organic brain disease

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Pre-morbid personality

• Greater likelihood of paranoid/schizoid
  personality disorder
• Persistent delusional disorder may represent an
  accentuation of pre-existing paranoid personality
  disorder
• Schizoid personality disorder characterised by
• PERVASIVE INDIFFERENCE TO SOCIAL RELATIONS
• DECREASED RANGE OF EMOTIONAL EXPRESSION
• ECCENTRIC, ALOOF, COLD
• INDIFFERENT TO PRAISE/CRITICISM
• LACK OF CLOSE FRIENDS/CONFIDANTES

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Genetic factors

• Some evidence for genetic loading (Kay 1972)
• However, methodological problems include
  Variability in diagnostic
  criteria Unreliable information on family
  pedigree Overinclusiveness of psychotic phenomena
• Late-onset makes genetic studies problematic
  
• HLA sub-types show some heritability in
  persistent delusional disorder (HLA B37) Naguib
  et al 1987

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Socio-demographic factors

• Early postulated associations with un-married
  status and low fertility (Post 1966), subsequent
  studies have not confirmed this (Kay and Roth
  1961)
• Social isolation has a consistent association
  with persistent delusional disorder, suggested as
  a consequence of maladaptive personality traits
  (Kay 1972), BUT social isolation of onset in
  later life also implicated (Almeida et al 1995)
• Excess of females with persistent delusional
  disorder (Ranges from 31 to 452). Not simply a
  reflection of later onset of psychotic disorder
  in women. Theories include an excess of Dopamine
  receptors in older women and delayed onset of
  psychotic disorder through early use of coping
  mechanisms
• Association with social class not informative

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Sensory impairment

• Experimental hearing loss associated with
  paranoid symptoms and auditory hallucinations
  
• Hearing impairment present in upto 40 of people
  with persistent delusional disorder
• Earlier onset may be related to social isolation
  and suspiciousness
• Psychotic symptoms may be diminished after
  improving hearing
• Some limited evidence for an association with
  visual impairment

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Organic brain disease

• Classically, late-onset psychotic disorders have
  been associated with Organic Brain Disease, but
  the majority of clinical longitudinal studies
  provided little evidence for a significant
  association
• Neuro-imaging studies HAVE found strong
  associations between persistent delusional
  disorder and cerebrovascular lesions, cortical
  atrophy and ventricular enlargement (Almeida et
  al 1995)
• A variety of neurological soft signs have been
  associated with persistent delusional disorder
  (e.g. signs of extrapyramidal and frontal lobe
  damage)

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Clinical features

• Presence of elaborated/systematised delusions is
  common in persistent delusional disorder
• Delusions of persecution/reference frequent.
  Sexual themes not uncommon. Passivity phenomena
  in up to 40
• Relative preservation of personality/absence of
  negative symptoms
• Auditory hallucinations can be conspicuous, but
  not essential for diagnosis (2nd/3rd
  person/olfactory/tactile)
• Depressive symptoms do not predominate clinical
  picture
• Some evidence for mild cognitive impairment
  associated with persistent delusional disorder.
  One study has found that greater number of
  psychotic symptoms associated with less severe
  cognitive impairment
• Influence of pre-occupation with psychotic
  symptoms, poor cooperation and side-effects of
  neuroleptic drugs have to be taken into account

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Differential Diagnosis (What else could it be?)

• Severe depressive disorder Delusions often have
  different content, e.g. nihilistic,
  worthlessness, guilt. Also, presence of other
  depressive symptoms and other clues in
  history/mental state examination
• Dementia Delusions and hallucinations occur in
  up to 15 of sufferers, but cognitive impairment
  progressive and delusions more fleeting/fragmented
  
• Schizo-affective disorder Presence of symptoms
  typical of both mood disorder and schizophrenia
  but core elaborated delusional system more
  prominent than mood-related symptoms
• Transient paranoid reactions/personality
  disorder/organic psychoses /drug-induced psychoses

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Management

• More helpful to assess in persons home, since
  delusions may be situation-specific
• Sufferers often known to neighbours, police,
  social services, other public bodies
• Rapport difficult to achieve initially
• Remediable factors such as hearing impairment may
  bring about significant reduction in severity of
  psychosis
• Social interventions may not be successful,
  particularly if life-long solitariness
• Hospital admission may result in honeymoon
  period

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Drug Treatment

• Placebo-controlled trials are rare
• Most studies of traditional neuroleptics have
  found improvement in psychotic symptoms (27 to
  66)
• Successful remission/partial remission more
  difficult to achieve than in patients with
  schizophrenia who have grown older
• Presence of accompanying physical illness,
  altered metabolism/receptor sensitivity,
  polypharmacy, variable compliance and cognitive
  impairment are all complicating factors
• Oral neuroleptics at 10 to 25 of conventional
  dose used
• Low dose depot neuroleptics beneficial (esp.
  compliance)
• Atypical neuroleptics minimise risk of
  extrapyramidal side-effects

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Outcome

• Most people follow a chronic course complete
  remission rare
• Marked reductions in psychotic symptoms, however,
  can be achieved
• Progression of cognitive impairment not as fast
  as in dementia
• Risk of tardive dyskinesia kept lower by smaller
  doses of neuroleptics/use of atypical
  antipychotics
• Most people kept on caseloads of community teams
  for considerable lengths of time in view of poor
  integration into community (i.e. problems with
  neighbours etc)

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Reading List

• Articles
• Almeida, O.P., Howard, R.J., Levy, R., David,
  A.S. (1995) Psychotic states arising in later
  life. Psychopathology and nosology and The role
  of risk factors. British Journal of Psychiatry
  166, 205-228
• Hymas, N., Naguib, B., Levy, R. (1989) Late
  paraphrenia a follow-up study. International
  Journal of Geriatric Psychiatry 4, 23-29
• Howard, R., Almeida, O.P, Levy, R. (1994)
  Phenomenology, demography and diagnosis in
  late paraphrenia. Psychological Medicine
  24, 397-410 BOOKS
• Naguib, M, Levy, R. (1995) Paranoid states in
  the elderly and late paraphrenia. In Jacoby, R.
  Oppenheimer, C. (Eds) Psychiatry in the elderly.
  Oxford University Press, Oxford
• Howard, R (1997) Drug treatments in paranoid
  states of the elderly. In C Holmes and R Howard
  (Eds), Advances in Old Age Psychiatry
  Chromosomes to Community Care. Wrightson
  Biomedical Publishing, London.