Mental Illness in Older Adults

Introduction

Mental illness is common in older adults, and those who have a concurrent physical illness are particularly vulnerable. Although these conditions tend to be underdetected and undertreated, their outcome with appropriate management is often excellent. This chapter reviews the main mental health disorders aside from dementia.

Depression and Anxiety in Older Adults

Despite the commonly held negative stereotypes of aging as mainly loss and decrepitude, and despite depression and anxiety being major causes of mental health problems in later life, rates of late-life depression and anxiety are paradoxically lower than rates reported for younger or middle-aged adults. Rickards and Leiberman estimate depression prevalence of between 20% and 45% and 25% and 40%, respectively, in community-dwelling populations of older people. Depression prevalence rates are elevated when taking account of medical conditions. Nevertheless, even in these cases, depression is not an inevitable outcome. For example, the prevalence of depression after stroke is 33%. Depending on methods of sampling and measurement, prevalence of depression in Parkinson disease is reported as high as 75%. However, this high prevalence estimate should be tempered by the clinical challenge of an accurate diagnosis of depression in Parkinson disease because of symptom overlap.

In a systematic review of community-based studies assessing prevalence of late-life depression, Beekman and colleagues calculated an average prevalence rate of 13.5% for clinically relevant depression symptoms. More recently, McDougall and coworkers reported an estimated prevalence of depression among people aged 65 years and older of 8.7% from a large epidemiologic study conducted across England and Wales, with a prevalence rate for severe depression of 2.7%. There does not appear to be a relationship between age and prevalence of depression, whereas factors associated with increased rates of depression were being female, experiencing medical comorbidity and disability, and levels of social deprivation. Wilson and associates reported elevated prevalence (21%) rates of depression in very old people (80 to 90 years) living alone.

The Centers for Disease Control and Prevention note that, contrary to popular belief, older people experience less frequent occurrence of mental distress, with lifetime histories of depression at 10.5% and anxiety at 7.6% that are lower than those reported for depression and anxiety (19.3% and 12.7%, respectively) in adults in midlife (50 to 64 years).

Depression rates may also be elevated in those populations who reside in institutional settings. Thakar and Blazer reported rates of depression as high as 35% in residents in long-term care (LTC) facilities in the United States and note that depression is very often underrecognized. Seitz and colleagues carried out a literature review of the prevalence of psychiatric disorder in LTC and identified 26 studies of depression prevalence and reported rates of 5% to 25%, with a median prevalence rate of 10%. Depressive symptoms were more prevalent, ranging from 14% to 82%, with a median prevalence rate of 29%. This suggests that depression may be elevated in residents in LTC, but perhaps arriving at a formal diagnosis of depression is more difficult in the context of an LTC facility. Likewise, providing treatment for depression in an LTC facility can be challenging. As yet, there is no robust evidence base for the application of structured psychological therapies for depression in LTC, although the evidence, such as it is, suggests that older people may benefit from a psychosocial approach to emotional distress.

In effect, rates of depression in community-dwelling older adults are surprisingly uncommon when considering the challenges that can be posed by age. Moreover, the prevalence of depression is lower in older adults compared to adults of working age.

Blazer suggests three protective factors associated with aging explain the low rate of depression in later life. These factors are better emotional regulation skills through selectively optimizing positives, increased wisdom through learning to deal with adversity and uncertainty, and resilience as a result of coping better with stressful events. Jorm suggests that depression and anxiety rates reduce with age because of a multitude of factors, such as decreased emotional responsiveness (evidence suggests that levels of neuroticism decrease with age); increased emotional control (older people have developed skills in coping strategies that result in better emotional stability); and psychological immunization (people develop a resilience and resistance to depression through exposure to adverse life events).

The relationship between depression and dementia is a complex one. Depression can contribute to development of dementia or worsening of cognitive problems in dementia. In a large retrospective cohort study involving more than 35,000 participants, researchers found that depression in midlife was associated with increased risk of later dementia by 20% and later life depression by 70%. Having midlife and later life depression increased the risk of dementia by 80%. Dementia, especially at an early stage, can lead to depression. This is especially true when the patient has good insight and realizes the impact of this degenerative and terminal illness on quality of life and stress on caregivers. Vascular dementia and Alzheimer dementia are more associated with depression than are other types of dementia.

Anxiety may be more common in later life than depression, but anxiety disorders are much less common than anxiety symptoms. Furthermore, it may be less common for older people to receive a diagnosis of an anxiety disorder on its own, but it may be more likely as a comorbid diagnosis with depression. Until relatively recently, there were no specific psychometrically robust measures of anxiety in older people.

Generalized anxiety disorder (GAD) and specific phobias are the most common anxiety disorders. Wolitzky-Taylor and coworkers in a comprehensive review, reported the prevalence for all anxiety disorders in later life from 4.5 to 14.2%, and cite the Epidemiological Catchment Area study prevalence as being 5.5% and thus lower than in adults of working age. Wolitzky-Taylor and associates report prevalence of GAD between 1.2% and 7.3% in the studies in their sample, and lifetime prevalence for GAD is estimated at 3.6%. However, a full understanding of late-life anxiety prevalence is challenging because of variable methodologic quality, sampling issues, operational definitions, and the entry age for which anxiety in later life is identified (in some studies this is defined as 55 years). Some anxiety disorders in later life appear uncommon; for example, the prevalence of obsessive compulsive disorder (OCD) is reported as only 0.8% to 1.0%. Of note for understanding anxiety disorders in later life is that conditions such as GAD appear to be of long duration and, unlike depressive disorders, are less likely to spontaneously remit.

Bryant and colleagues examined the prevalence for late-life anxiety disorders and symptoms in community-dwelling and clinical samples. The most common anxiety disorders are specific phobias (1.4% to 25.6%) and GAD (1.3% to 7.1%), with a low prevalence for panic disorder. However, Bryant and coworkers comment that data on panic disorder are sparse, but when symptoms are measured, rates can be as high as 26.2%. As with previous reviews, reported prevalence rates vary considerably, with prevalence for anxiety disorders in community-dwelling older people of between 1.2% and 14% and prevalence for anxiety symptoms in community samples between 15% and 52.3%. Because symptom reporting is variable, it is not possible to be sure that samples are comparable. It is not surprising that prevalence rates are higher in clinical samples, reported as between 15% and 56%. Clinical samples also vary because of the overlap between anxiety symptoms and physical symptoms, as well as lack of valid psychometric tools for assessing anxiety disorders, which makes accurate diagnosis challenging. Nonetheless, it should be evident that there is a higher prevalence of anxiety symptoms in physically ill hospitalized older people and that the presence of anxiety (disorders and symptoms) is associated with an increased risk of poorer outcome.

Posttraumatic stress disorder (PTSD) in later life is an interesting condition with a different course linked to the life history of individuals and, in some cases, cohorts. In a contemporary review, Bottche and associates divide PTSD into late or early life acquired symptoms. PTSD in older people acquired earlier in life may be more common in veterans or in holocaust survivors, whereas PTSD symptoms acquired later in life are more likely to occur after accidents or natural disasters. Overall lifetime prevalence rates of PTSD are lower in older (3.9%) than in younger (6.1%) or middle-aged adults (6.2%), but when considering higher risk populations such as those with war trauma experience, prevalence rates are much higher (3% to 56%). High rates of PTSD are reported in holocaust survivors (24.2%). Data about the lifetime course and outcome of PTSD following early traumatization remain inconclusive.

Management of Mood Disorders in Older Adults

The management of depression in physically ill older adult patients is essentially the same as for depression in general. Antidepressant and psychological therapy are equally effective in older and younger adults, although in pharmacotherapy, medical comorbidities and the possibility of adverse consequences or interactions between antidepressants and other drug treatments must be considered carefully. Antidepressant prescribing for depressed older people appears to have increased in recent years, perhaps because of the perceivably superior safety profile of selective serotonin reuptake inhibitors (SSRIs).

Drugs associated with depression include propranolol, β-blockers, antiparkinson drugs, cimetidine, clonidine, estrogens and progesterone, tamoxifen, and dextropropoxyphene. Depression is also associated with malignant and cerebrovascular disease; myocardial infarction; and thyroid, parathyroid, and adrenal endocrine disturbance.

Removal of depression-causing medication and treatment of illnesses associated with depression may improve mood. Antidepressants should be given at adequate doses for a minimum of 4 weeks before concluding they are ineffective and changing to a different class. If response is poor, consider whether the patient is adhering to the treatment and increase to a higher dose.

Coupland and colleagues reported a cohort study investigating classes of antidepressant drugs. All classes were associated with increased risks of adverse events, but there were differences in the type and frequency of serious effects across medication classes. The SSRIs were associated with an increased risk of falls (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.58 to 1.73), and citalopram, escitalopram, and fluoxetine were also associated with hyponatremia (HR, 1.52; 95% CI, 1.33 to 1.75). Trazodone, mirtazapine, and venlafaxine were associated with higher risks of all-cause mortality and several potentially life-threatening events, including attempted suicide or self-harm and stroke or transient ischemic attack. The study showed that low-dose tricyclic antidepressants remain popular—at least in the United Kingdom (31.6% of all antidepressant prescriptions)—and did not have the highest hazard ratio for any of the adverse outcomes reported. Important interactions between unknown patient factors and drug choice could still have occurred. For example, medication such as venlafaxine is typically used in more severe or treatment-resistant depression (which may be indicative of severe medical comorbidity). Trazodone and mirtazapine are more likely to be prescribed to patients with serious sleep disturbance or agitation, factors that again are often linked with more serious physical ill health. As the dose of tricyclic antidepressants increased, the risks of all-cause mortality, falls, seizures, and fractures increased. For most adverse outcomes, the high-risk periods were during the month after starting or stopping antidepressants.

Depression in older adults frequently fails to respond to initial treatment. Pharmacologic strategies for treatment-resistant depression may be useful despite the toxicity risk. Nortriptyline, lithium, and bupropion were found to be useful additive treatments in cases where an SSRI is the initial treatment. Older people require careful monitoring for effectiveness and adverse effects, with provision of information (to the patient and caregiver) about the risks of falls, confusion, agitation, and increased suicidal ideation. Although people with dementia are at an increased risk of developing depression, the evidence for efficacy of antidepressants in these patients is poor.

Pathologic crying, or more rarely pathologic laughing, can be a distressing feature of depression, and there is evidence that SSRIs can be efficacious in reducing symptoms within days of commencing therapy.

The safety profile of electroconvulsive therapy (ECT) in older patients with depression is very good. A wide spectrum of clinical responses has been demonstrated, including reduction of anxiety symptoms. ECT is at least as effective in adults aged 60 and older as those aged 18-60 years and may positively influence outcome. Unilateral electrode placement appears as effective as bilateral in older patients, but there is evidence that unilateral electrode placement is associated with fewer memory-related side effects in this age group.

Psychological treatments are underused in older age. This is partly because their availability is often limited. There is also a misconception that older people lack the psychological flexibility to benefit from psychotherapeutic interventions. Older adults appear to respond particularly well to cognitive therapy for depression; this is effective both in an individual setting and (more economically) in groups. The focus is often on real or threatened losses (bereavement, physical health, financial security) and on fears of impending death. Brief, highly focused cognitive behavioral therapies such as problem-solving therapy are being advocated increasingly for older people, including those with some degree of cognitive dysfunction. These approaches may be effective when used in people at high risk to prevent, as well as treat, depression in older age.

Another brief talking therapy, interpersonal psychotherapy, has also been shown to be effective in older people. Collaborative care has emerged as a helpful approach toward integrating primary and secondary care teams and combining the use of a range of treatment modalities. Tailored collaborative care is associated with substantial benefits (compared with treatment as usual) in terms of improvement in depressive symptoms, better physical functioning, and enhanced quality of life.

Suicide in Older Adults

The highest suicide rates are found in males aged 75 years and older. Suicide among older adults in North America is almost twice as common as in the rest of the population, and this finding is replicated in most other countries. About 90% of those who commit suicide have at least one diagnosable mental illness. The most common psychiatric disorder associated with completed suicide is depression.

Men who commit suicide more commonly use violent methods (e.g., hanging or guns), whereas women more commonly use overdoses or self-poisoning methods. Older people are more successful when it comes to completed suicide compared to younger people. Factors that may explain this include more physical fragility and illness in older people and higher chance of social isolation (therefore, they are unlikely to be interrupted or stopped). In addition, research has shown that older people are more determined to die when they attempt suicide and are less impulsive than younger people. Any suicidal attempt or gesture by an older person should be taken very seriously. Multiple physical and mental illnesses increase the risk of suicide. Physical illnesses such as epilepsy, chronic obstructive pulmonary disease, congestive heart failure, and mental health disorders (e.g., anxiety, depression, and bipolar disorders) are specifically associated with higher rates of suicide. Other factors associated with suicide in older adults include bereavement, substance misuse, increasing social isolation, deteriorating physical health, and pain.

Attempted suicide closely resembles completed suicide in older adults. Psychiatric illness, particularly depression, is prominent in most cases. Minor depression and personality dysfunction are associated with suicide attempts of relatively low intent and higher levels of psychosocial stresses. Hopelessness persisting after remission of other depressive symptoms is associated with suicide attempts and completed suicide. On the other hand, personality disorders and substance misuse disorders may have a lower prevalence in older populations and are therefore less associated with completed suicide compared to younger populations. Suicide is much more closely associated with depression in older than in younger subjects, and the best predictor of suicidality is the current severity of depression. The increased rate of suicide in those experiencing physical ill health is mediated by depression.

Somatoform Disorders

Somatoform disorders are those in which physical symptoms occur in the absence of any or sufficient organic pathology to account for them and include conversion disorder, somatization disorder, pain disorder, and hypochondriasis. They are not due to malingering or fabricated symptoms, and the patient experiences the symptoms presented. Psychological contributory factors can usually be identified. They are considered as anxiety disorders and can present outside psychiatry in medical settings.

The two main classification systems in psychiatry—the International Classification of Diseases, tenth edition (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders , fifth edition (DSM-5)—differ slightly in their definitions and subcategorizations of somatoform disorders. The ICD-10 diagnosis of somatoform disorders (F45) defines the main feature of these disorders as “repeated presentation of physical symptoms together with persistent requests for medical investigations.” Additional features are that patients with somatoform disorders will not be reassured by normal test results and, even if physical cause is found, it does not explain the severity of the emotional distress or the preoccupation. The ICD-10 includes the following subcategories for somatoform disorders: somatization disorder; undifferentiated somatoform disorder; hypochondriacal disorder; somatoform autonomic dysfunction; persistent somatoform pain disorder; other somatoform disorders; and somatoform disorder, unspecified. The DSM-5 groups somatoform disorders under one heading called “somatic symptom and related disorders” and defines these disorders as presenting with “excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns.”

The symptoms are not required to be “medically unexplained,” and the main factor is the complaints of distressing and chronic somatic symptoms that are associated with significant emotional response.

Prevalence

The estimated prevalence of somatoform disorders in the general population is approximately 6%. Prevalence figures in the older adult population are variable depending on clinical settings. (Hospital-based studies show higher prevalence compared to community-based samples.) Older people often develop exaggerated bodily complaints in the context of physical illness. Physically ill patients may also have generalized anxiety or panic symptoms. The common medical disorders producing anxiety symptoms are endocrine, cardiovascular, pulmonary, and neurologic conditions. A thorough history should help to establish the temporal relationship of psychiatric symptomatology and the onset of medical illness. Although the onset of somatoform disorder is usually in early life and runs a chronic course, somatizing patients avoid psychiatrists in youth and adulthood and so it is not uncommon for them to arrive at a clinic for the first time in older adulthood. There is evidence that somatizing presentations are common among older primary care attendees.

Studies provide various estimates for the prevalence of somatoform disorders in the older adult population depending on their methodologies and clinical settings. The prevalence varies from 1.5% to 13%. The Epidemiological Catchment Area study from the United States suggests the prevalence is the same and rare (0.1%) throughout adult life when the disorder is defined as having 12 or more unexplained medical symptoms. Rates of persistent fatigue are also similar across age groups and occur in more than a quarter of adults of all ages.

These patients usually have clear symptoms of depression or anxiety. Their bodily complaints tend to be restricted to one or two body organs or systems, and they are preoccupied with the possibility of serious physical illness. They demand investigation rather than treatment. In contrast, hypochondriacal preoccupation presenting for the first time in older adults is unlikely to be secondary to anxiety and depression. Hypochondriasis is a persistent, unrealistic preoccupation with the possibility of having at least one serious disease in which normal sensations and appearances are often misinterpreted as abnormal and as signs of disease and the patient cannot accept reassurances from doctors. Older adult patients only rarely present with conversion reactions (e.g., paralysis) or dissociative amnesia in response to stressful experience. Treatment of associated psychiatric conditions may lead to improvement in somatic attributions.

Some studies suggested an association between early traumatic experiences and higher prevalence of somatization in older adults. These somatic symptoms were thought to be manifestations of complex PTSD. Somatoform disorder is associated with higher use of health services. Women have double the risk of somatoform disorders compared to men.

Management

Treatment of somatic disorders should not only focus on medication but also incorporate psychosocial support and psychotherapy. There is good evidence to suggest that psychotherapy is effective in patients with severe somatoform disorder (compared to treatment as usual). Somatoform disorders are associated with high occurrence of other psychiatric comorbidity (anxiety and affective disorders), and these should be treated accordingly. St. John's wort was also found to be helpful in reducing the severity of somatoform disorders, but cautious use is recommended because of its potential to interact with other drugs. It may be a useful option in patients who prefer to avoid psychotropic medication or when those medications are contraindicated.

Key Points

Somatoform disorders describe multiple physical symptoms without an identifiable organic cause. The symptoms are real and experienced by the patient (which is a key difference from malingering or fabricated symptoms).
Somatoform disorders are usually associated with mental health problems (especially depression, anxiety, or panic symptoms). Establishing the temporal relationship between the somatic and psychiatric symptoms can be difficult.
Management involves addressing the comorbid psychiatric symptoms and incorporating psychological, social, and spiritual (if applicable) interventions as part of multidisciplinary and holistic care.

Psychotic Disorders

Late-Life Psychosis

Schizophrenia-like psychotic illness later in life, not caused by or resulting from an organic or affective disorder, has been variously termed paraphrenia, late paraphrenia , and late-onset schizophrenia . In 2000, the International Late-Onset Schizophrenia Group defined the terms late-onset schizophrenia and very late-onset schizophrenia for schizophrenia-like illnesses with onsets between age 40 and 60 and after age 60 years, respectively. The term late-onset schizophrenia is used to describe these conditions within this chapter. More circumscribed delusional disorders also occur in late life; these are referred to as late-life delusional disorders . In addition, the challenges posed by patients with long-standing psychotic illness (usually schizophrenia) who “graduate” to old age are also considered.

Late-Onset Schizophrenia

The original concept of late-onset schizophrenia referred to the first onset of persecutory delusions and associated hallucinations after the age of 60 years in the absence of an affective or organic psychosis. It may thus be viewed as schizophrenia or a schizophrenia-like illness in older adults. Table 56-1 provides a summary of the phenotypic differences according to age.

TABLE 56-1

Schizophrenia-Like Psychosis at Different Ages of Onset

Onset ->	Typical (15-40)	Middle Age (41-65)	Very Late (>65)
F : M ratio	0.6 : 1	2 : 1	Up to 8 : 1
Poor premorbid function	++	+	−
Family history of schizophrenia	++	++	−
Sensory deficits	−	−	+
Negative symptoms	+++	++	−
Thought disorder	+++	+++	−
Brain structural (strokes/tumors)	−	−	+
Dose antipsychotic	+++	++	+
Tardive dyskinesia risk	+	+	++

Epidemiology

Although the incidence of schizophrenia is highest in people aged 16 to 25 years, there is a second peak in incidence in those aged older than 65. Almost a quarter of the affected patients develop schizophrenia at the age of 40 years or older.

The prevalence of nonaffective psychosis in people aged older than 65 years has been reported as 2.3% in women and 1.7% in men. Data from general medical practices regarding patients with treated schizophrenia (1997-1998) indicate that prevalence peaks in women in the 65- to 74-year age group compared with the 45- to 54-year age group in men, reflecting the higher prevalence of late-onset schizophrenia in women. The incidence of late-onset schizophrenia has been reported at 12.6/100,000/year. Incidence is positively correlated with age, with first admission data suggesting an increase of 11% for every 5-year increase in age. In the United Kingdom, African-Caribbean older people are more likely than white British older people to be in contact with services for a new diagnosis of psychosis. Prevalence of late-onset schizophrenia is likely to be underestimated by community surveys and treatment data, as those affected are far less likely than the rest of the population to cooperate with survey investigators and often refuse treatment. They may only be treated compulsorily and in the context of particularly severe behavioral disturbance or when the illness affects their physical health.

Causation

About 10% of the relatives of patients developing schizophrenia in middle age also have the disease; this is similar to the proportion for patients with early-onset schizophrenia. In family studies of late-onset schizophrenia, however, the rate of schizophrenia in first-degree relatives is much lower. Standardized instruments were not used in the late-onset schizophrenia studies, however, so the data are not directly comparable to those from fully operationalized family studies of younger subjects.

The influence of personality, social, and environmental factors in association with genetic predisposition is clearly complex. Patients with late-onset schizophrenia are often socially isolated and live alone. They are more likely to have paranoid or schizoid premorbid personalities that are characterized by suspicion, sensitivity to setback and disappointment, and preoccupation with what others think about them. Their isolation is often long-standing and may well be secondary to personality traits. They are predominantly unmarried women without close family or personal attachments. Those who do marry often end up divorced or separated. However, premorbid educational, occupational, and psychosocial functioning is less impaired in patients with late-onset compared to early-onset schizophrenia. Fertility is reduced. The consequent social isolation, which is often increased by sensory isolation and retirement, can result in increasing preoccupation with their internal world.

Recent evidence from cohort studies suggests that a history of psychotic symptoms, cognitive problems, poor physical health, visual impairment, and negative life events are risk factors for late-onset psychosis.

In terms of sensory impairment, there is a confirmed association between deafness and very late-onset schizophrenia in particular. These patients frequently have a conductive hearing loss acquired in early life to such a degree as to impair social interaction, resulting in “social deafness.” Visual impairment may be present but is probably no more common than in normal older adults. Patients with late-onset schizophrenia have been found to come from the lower social classes or socioeconomic groups ; this may result from social deterioration secondary to the disease, as also occurs in younger people with schizophrenia.

Presentation and Clinical Features

Patients often arrive for medical services because they complain to the police and neighbors with bizarre accusations over a period of time or because of concern triggered by extreme self-neglect or odd behavior. There are no qualitative differences between the positive symptoms of early-onset schizophrenia and those of late-onset schizophrenia. The clinical presentation of late-onset schizophrenia is quite varied. Patients are in clear consciousness. Usually their mood is normal, although occasionally a secondary depressive mood is found. The history may be difficult to elicit from patients with late-onset schizophrenia because they tend to be suspicious and hostile.

Delusions are a central feature. Persecutory delusions are particularly common. Sexual themes are common in women. The patient may accuse a man or men of entering her bed at night and molesting her sexually. Delusions of influence and passivity phenomena are frequently reported. Patients may describe their bodies as being controlled, or they may complain that some power affects them and they are made to do things against their will. Thought insertion, withdrawal, and broadcasting, however, are fairly rare, and formal thought disorder is almost nonexistent.

Hallucinations are frequently experienced. Those with late-onset schizophrenia experience a great number of different types of hallucinations. Auditory hallucinations are the most common and usually have an accusatory and/or insulting content. The voices speak in the second or the third person with “running commentary” occasionally encountered. Hallucinations of bodily sensation are also found. Patients complain of being vibrated, raped, or forced to have sexual intercourse. Olfactory hallucinations often relating to poisonous gas are encountered. Visual hallucinations are rare in late-onset schizophrenia and, if present, should raise the strong suspicion of an underlying organic state. Comorbid depression and suicidal ideation are common.

It is not only social and sensory isolation that can make people vulnerable to psychosis but also a more vulnerable brain. Older adults' cognitive function is often mildly impaired at initial presentation, to a much lesser degree than found in dementia but significantly more than in psychiatrically healthy age-matched controls. Decline is usually slowly progressive, with only a small group of patients entering the dementia range at 3-year follow-up.

Studies of older adults with psychosis have found lower quality of life to be associated with depression, positive and negative symptoms, cognitive deficits, physical disorders, and poorer perceived health, as well as social factors including loneliness and financial strain.

Brain Imaging Studies

Structural neuroimaging findings in late-onset illness are similar to those found in patients with early-onset schizophrenia. A representative computed tomography (CT) study has reported increased mean ventricle-to-brain ratio with cortical sulci appearances remaining within normal limits. Single-photon emission computed tomography (SPECT) studies have found reduced regional cerebral blood flow (rCBF) in late-onset psychotic patients compared to controls, appearances that are similar to those found in early-onset schizophrenia. Magnetic resonance imaging (MRI) has demonstrated increased periventricular hyperintensities and thalamic signal hyperintensities in late-onset schizophrenia, which have led to the suggestion that cerebrovascular disease may be significant in the pathogenesis of the condition, although these findings have not been consistently replicated and may reflect the overrepresentation of individuals with cerebrovascular disease risk factors.

A number of studies using positron emission tomography (PET) scanning have shown increased basal ganglia dopamine D2 receptors in late-onset schizophrenia. However, these findings have not been consistently replicated, particularly in drug-naive subjects, suggesting that some of the differences initially reported may reflect treatment rather than disease-induced receptor alteration.

Neuropsychologic Testing

Patients with late-onset schizophrenia have been shown to perform less well on the Mental Test Score and Digit Copying Test than age-matched controls. Deficiencies have also been shown on full-scale IQ tests, tests of frontal lobe function, and verbal memory tasks. The presence of brain abnormalities was not associated with particularly low neuropsychologic test scores. When patients with late-life schizophrenia are compared to those with young-onset disease, they have less neuropsychologic deficit in abstraction and cognitive flexibility but more global impairment.

Assessment, Treatment, and Course

The initial management of late late-onset schizophrenia involves assessment and engagement. Patients should be assessed at home because they are unlikely to comply with outpatient appointments and because their psychotic symptoms may be strongly triggered by cues within their normal environment and less obvious away from it. If hospital admission is needed, it commonly results in an apparent complete remission followed by relapse on return home. Access to the home of a patient with late-onset schizophrenia can be difficult. This can lead to assessment under the Mental Care Act (in the United Kingdom) or involvement of the courts and police according to local country legislation.

Late-onset schizophrenia may run a chronic course, but recent studies have shown remission rates of 48% to 60% after treatment. Attempts at treatment should begin in the community wherever possible, with hospital admission reserved for patients with particularly severe or dangerous behavioral disturbance or poor self-care. Medication, psychosocial intervention, and ECT have all been reported to produce temporary remission. Adequate antipsychotic treatment produces improvement in psychotic symptoms but not much improvement to the patient's pretreatment level of social functioning. Dosages are much lower than those used in younger patients with schizophrenia because people with late-onset schizophrenia are often very sensitive to extrapyramidal side effects. Patients do better (in terms of side effects, efficacy, and negative symptoms) with atypical antipsychotics, but risperidone and olanzapine are relatively contraindicated in those with cardiovascular morbidity or diabetes. A good response to antipsychotics has been found in patients with very late-onset schizophrenia-like psychosis, even better than in late-onset schizophrenia and older adult early-onset schizophrenia patients. Patients are often not adherent to medication, particularly if they live alone. Even when compliance is assured, many patients with late-onset schizophrenia remain psychotic, although they may be less distressed by their symptoms and less disturbed in their behavior. Community psychiatric nursing involvement has been shown effective. There is conflicting evidence regarding whether depot medication improves adherence.

An attempt should be made to correct remediable physical or environmental contributory factors, particularly through alleviating sensory or social isolation. A flexible approach is required, and patients' characteristic insistence on remaining isolated (as they have often been for much of their lives) must be respected. Patients' requests for rehousing should be resisted if they are secondary to delusional beliefs; if symptoms improve or even abate in a new home setting, this is usually only a temporary respite. Consideration of capacity is important to prevent self-neglect or financial abuse. Old “tormentors” reemerge, and new ones may be acquired. Antipsychotic medication is a vital component of the total therapeutic package but is far from the whole answer; improvisation and ingenuity in engaging these patients and then retaining them in long-term follow-up is crucial to maintain both compliance and an optimal level of social functioning and to reduce risk of symptomatic relapse.

Late-Life Delusional (Paranoid) Disorder

It has been estimated that 4% of the community-living older adult population experience some persecutory delusions. Such beliefs are commonly associated with a neuropsychiatric disorder. A primary delusional disorder is present when there is evidence of persistent, nonbizarre delusions that are not attributable to another psychiatric disorder or any organic cause. Delusional disorder refers to persistent delusions without evidence of schizophrenia, schizophreniform, or mood disorders. Hallucinations are not prominent. There is no evidence of organic dysfunction. The distinction between such disorders and late-onset schizophrenia reflects the relative absence of schizophrenia-like features other than delusions in the late-life delusional group. Delusional disorder occurs in middle as well as late life. Men tend to be affected earlier than women (40 to 49 years vs. 60 to 69 years).

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here