Psychosis in the Older Patient Module 2

1. Psychosis in the Older PatientModule 2 Thomas Magnuson, M.D. Assistant Professor Division of Geriatric Psychiatry Department of Psychiatry UNMC Updated 1/25/06

2. Objectives Upon completion the learner will be able to: • List the common etiologies for psychosis in the elderly • Describe the common presentations of these etiologies

3. Dementia 50% of all demented patients will have psychosis • 30% have paranoid delusions • Concrete, interpersonal • Specific people stealing, spying • “Capgras-like” delusions • 20-50% hallucinations • Visual slightly more than auditory • Women more than men • NH, hospital more than the community

4. Dementia Present in all forms of dementia • Certain considerations for some dementias • Lewy Body Dementia • Cortical and subcortical features • Parkinsonian-like presentation • Fluctuating course • Vivid visual hallucinations • Using antipsychotics worsens their symptoms • Even newer, atypical agents • May even increase mortality rate

5. Dementia • Parkinson’s dementia • Common outcome • Occurs late in the process • Medication-derived • Using traditional and some atypical antipsychotics worsens their movement • Clozapine and Seroquel less likely to add to movement problems

6. Delirium • Transient, global reversible cerebral dysfunction • Acute in onset • Fluctuating course • Inattention • 13-27% of hospital patients • Psychosis usually present • Delusions • Visual and tactile hallucinations

7. Delirium • Age over 60 is a risk factor • 28-44% after hip fracture • 38% admitted to a general hospital • Increased risk with preexisting cognitive impairment and degree of medical morbidity • Etiologies • Medications (48%) • Metabolic disorders (30%) • Neurological disorders (20%) • Infections (17%), Hypoxia (14%)

8. Delirium • Older patients ……..medical conditions • Younger patients ….alcohol intoxication or withdrawal • Higher rates of mortality than non-delirious patients • More likely to develop dementia • More likely to lose independence

9. Delirium • Multiple etiologies • Drug intoxication and withdrawal, metabolic problems, CV disorders, CNS disorders, infections, post-op, sleep deprivation • most likely multifactoral • Only 36% have one etiology

10. Delirium • Among previously community-dwelling elderly • Delirium led to prolonged hospital stays • Increased risk of institutional placement • Only 4% had complete resolution during the stay • Not as acute or reversible as once thought • Chronic delirium can occur • Herald sign in some who will develop dementia

11. Substance-induced Psychotic Disorder • Iatrogenic • Common therapeutic agents • Amphetamines • Ritalin (methylphenidate), dexedrine • Anticholinergics • Benedryl (diphenhydramine), Cogentin (benztropine), many antihistamines • Benzodiazepines • Tagamet (cimetidine) • Cortisone • “steroid psychosis”

12. Substance-induced Psychotic Disorder • Iatrogenic agents • L-dopa/carbidopa and dopamine agonists • Induced psychosis in Parkinson’s disease • Tertiary amine tricyclic antidepressants • Amitriptyline, imipramine, clomipramine • Methytestosterone • Pentazocin • Phenylpropanolamine

13. Substance-induced Psychotic Disorder • Recreational agents • Alcohol • By far the most employed in this cohort • Acute • Chronic • Also • Cocaine • Marijuana • Methamphetamine • Narcotics

14. Psychotic Disorder due to a General Medical Condition • Multiplicity of causes • Neurologic • Degenerative • Parkinson’s disease • Trauma • MVA • Tumor • Especially of the limbic system • Vascular • Stroke

15. Psychotic Disorder due to a General Medical Condition • Metabolic • Folate deficiency • Hemodialysis • Hepatic encephalopathy • Hypocalcemia • Hypo- and hyperthyroidism • Hypoglycemia • Hyponatremia • Malnutrition • Pancreatic encephalopathy

16. Psychotic Disorder due to a General Medical Condition • Metabolic • Parathyroidism • Pernicious anemia • SLE • Thiamine deficiency • Uremia • B-12 deficiency • Wilson’s disease

17. The End of Module Two on Psychosis in the Older Patient

18. Post test question 1 • A 70-year-old woman is brought by her husband for an outpatient evaluation. She has a 3-week history of hypersomnia, fatigue, and decreased attention span with intermittent episodes of confusion. She states that she felt “bugs crawling on her skin.” She has been taking thioridazine 300 mg daily at bedtime for chronic paranoid schizophrenia for several decades. Her chronic symptoms of auditory hallucinations are well controlled. Fluoxetine 20 mg daily was initiated 1 month ago because of complaints of poor motivation and low mood. • What is the most likely explanation for her current condition? Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.

19. What is the most likely explanation for her current condition? A. Acute exacerbation of schizophrenia with tactile hallucinations B. Neuroleptic malignant syndrome induced by thioridazine C. Progression of schizophrenia with increased negative symptoms and early dementia D. Major depressive disorder with psychotic symptoms refractory to fluoxetine E. Subacute delirium due to elevated thioridazine levels

20. Answer: E. Subacute delirium due to elevated thioridazine levels The clinical scenario most likely reflects a subacute delirium. The most common cause of subacute delirium in elderly persons is multiple medications. When a previously stable patient reports a new onset of confusion, it is essential to ascertain whether any new medications or dosage increases have been implemented. A medical evaluation should also be pursued in this setting and include measurement of electrolyte levels (hyponatremia may occur with psychotropic agents), thyroid studies, general chemistry profile, complete blood cell count, and, if clinically indicated, electrocardiogram and computed tomography scan of the head.

21. The clinical picture does not appear consistent with an exacerbation of psychosis, as the patient’s chronic hallucinations were well under control, and the new occurrence of tactile hallucinations is more suggestive of delirium than schizophrenia. The clinical picture is also inconsistent with neuroleptic malignant syndrome, which is characterized by rigidity, fever, autonomic instability, mental status change, and an elevated creatine kinase level. Neuroleptic malignant syndrome typically occurs shortly after the introduction of an antipsychotic medication for the first time. This clinical scenario is also distinct from negative symptoms of schizophrenia that include alogia (poverty of speech), avolition (absence of purposeful activity), and affective flattening. Negative symptoms tend to be longstanding difficulties that are not likely to present acutely or change in late life. It is possible that the patient has an underlying insidious dementia syndrome, but this is not likely to be the source of the current symptoms. Her symptoms of confusion and tactile hallucinations are more characteristic of delirium than depression.

22. The addition of a selective serotonin-reuptake inhibitor (eg, fluoxetine, paroxetine) may elevate the levels of other medications such as thioridazine through hepatic P-450 2D6 enzyme inhibition. Therefore, the addition of fluoxetine may serve to elevate levels of tricyclic antidepressants, morphine derivatives, phenothiazines, ß-blockers, some antihypertensives (eg, captopril), and some antiarrhythmic drugs (eg, quinidine). With the patient in question, who was taking thioridazine 300 mg daily, the addition of fluoxetine resulted in increased anticholinergic effects, contributing to sedation and confusion. Because of age-related decreases in hepatic function and vulnerability to cognitive impairment with anticholinergic effects, older persons are particularly susceptible to adverse effects from drug-drug interactions. Elevated levels of thioridazine may also be hazardous in that thioridazine can cause prolongation of QTc intervals. Go to next question.

23. Post-test question 2 • A 79-year-old man accompanied by his wife presents for evaluation. She has brought him to medical attention because of her concern about his delusional ideas. She reports that for the past year her husband has believed that people were breaking into their home to steal from them. He also believed that she had become unfaithful, and he confronted her about “running off” with men each week when she went shopping for groceries. The wife further reports that he has had increasing difficulty with memory impairment over the past 5 years such that she has assumed all household responsibilities, including the driving and financial duties. • On examination the patient is noted to be alert and cooperative with a full affect. His Mini–Mental State Examination score is 21/30. He has a history of benign prostatic hyperplasia but no other medical illnesses. His electrocardiogram reveals a left bundle branch block. Findings on general chemistry profile and urinalysis are normal. • What is the most likely diagnosis?

24. What is the most likely diagnosis? • Late-onset schizophrenia B. Delusional disorder C. Dementia with superimposed delirium D. Major depressive disorder with psychotic features E. Dementia with psychotic features

25. Answer: E. Dementia with psychotic features The patient in question has dementia with psychotic features. His persecutory delusions involving stolen belongings and spousal infidelity are two common themes associated with the psychosis of dementia. Delusions of this type may be contrasted to delusions of schizophrenia, which are more likely to be implausible and bizarre (eg, the belief that aliens have implanted computer chips in one’s head).

26. Late-onset schizophrenia (ie, onset after the age of 45 years) occurs in a subset of patients with schizophrenia and has several characteristic features. These features include a higher frequency among women, an association with nonspecific central nervous system injury (eg, periventricular hyperintensities seen on magnetic resonance imaging), a premorbid history of schizotypal personality, and an increased incidence of a family history of schizophrenia. Late-onset schizophrenia is not typically associated with overt cognitive deterioration. Delusional disorder is an uncommon condition, occurring in 0.01% of the population, most often seen in men over the age of 50 years, and characterized by discrete, plausible delusional ideas in the absence of memory impairment or other psychotic symptoms. Like late-onset schizophrenia, delusional disorder is not associated with memory impairment. Delirium and depression are other clinical conditions that must be excluded in this diagnosis. The chronicity of the patient’s condition speaks against delirium, and the absence of prominent mood symptoms makes depression an unlikely diagnosis. END.