Functional Mental Illness in Later Life: Psychosis

1. Functional Mental Illness in Later Life: Psychosis Neil Robertson Slides adapted from Dr Suzanne Reeves, Senior Clinical Lecturer, IOP.

2. Psychosis • Psychosis is an umbrella term for a number of psychotic illnesses that include: Drug induced psychosis Organic psychosis Bi-polar disorder Schizophrenia Psychotic depression Schizo-affective disorder (Taken from EPPIC)

3. Psychosis is characterised by: • Hallucinations – sensory perceptions in the absence of external stimuli – Types? • Delusions – a belief held with strong conviction despite evidence to the contrary • Formal Thought Disorder - presenting with incomprehensible thought patterns and/or language • Catatonia - state of neuro-genic motor immobility, and behavioural abnormality manifested by stupor, over-activity or rigidity

4. Negative symptoms • Blunted affect • Poverty of speech • Anhedonia • Lack of desire to form relationships • Lack of motivation

5. Psychotic Depression • Prevalence~2% -35% of older inpatients - 5% of young adults • Delusions - persecutory, hypochondriacal, poverty • Hallucinations - 2nd person auditory, olfactory, gustatory • Co-morbidity - physical co-morbidity in older compared to young adult patients

6. Alcoholic Hallucinosis • History of excessive alcohol intake • 2nd person auditory hallucinations most common • Persecutory ideas/ideas of reference ~ co-morbid depressive symptoms ~ cognitive impairment

7. Onset after 60 non-organic, non-affective Late-onset schizophrenia Late life psychosis

8. Schizophrenia

9. Classification and Incidence • Late-onset schizophrenia (LOS) - illness onset > 40 yrs -12.6 per 100 000 population per year • Very-late-onset schizophrenia-like psychosis (SLP) - illness onset > 60 yrs - 17-24 per 100 000 population (Holden et al, 1987)

10. Criteria for SLP • Onset > 60 years • Presence of fantastic, persecutory, referential, or grandiose delusions +/- hallucinations • Absence of primary affective disorder • MMSE >24/30 • No clouding of consciousness • No history of neurological illness/alcohol dependence • Normal blood chemistry (see Howard et al, 2000)

11. People with SLP have all the symptoms of schizophrenia except for... • Formal thought disorder • Negative symptoms

12. Plus some extra symptoms…. • Complex visual hallucinations • Partition delusions

13. Phenomenology of SLP • Non-verbal auditory hallucinations 70% • 3rd person auditory hallucinations 50% • Hallucinations in other modalities 30% • Delusions - persecution 85% reference 75% misidentification 60% partition 70% • Formal thought disorder, negative symptoms rare (<5%) and may represent misdiagnosed cases

14. Partition Delusions • Watched /overheard through partition 40% • Human intruder to home +-theft 34% • Non-human intrusion – gas/radiation 30% • Somatic effect of intrusion 20%

15. Howard, R et al (1992). Int J Geriatr Psychiatry 7; 719-724 PERMEABLE WALLS, FLOORS, CEILINGS AND DOORS. PARTITION DELUSIONS IN LATE PARAPHRENIA A partition delusion is the belief that people, objects or radiation can pass through what would normally constitute a barrier to such passage. These delusions have been reported to be common in late paraphrenia and late-onset schizophrenia. Such partition delusions were found in 68% of 50 patients with late paraphrenia, but only in 13% of patients with schizophrenia who had grown old and in 20% of young schizophrenics.

16. SLP: Cognitive Outcome • 25%  cognitive impairmentconsistent with a diagnosis of dementia within 3 years (Holden 1987, Reeves 2001) • 75% stable cognitive deficits

17. Risk Factors for SLP • Age:incidence  by 11% for every 5 yr  in age beyond 60 years • Female Gender: 4 x higher risk compared to men - not explained by higher proportion of ‘older’ women - ?loss of protective effect of oestrogen post menopause • Sensory Deficits :Auditory 40%, Visual 20% • Genetic Factors: more likely to have a FH of affective disorder • Pre-morbid Personality:paranoid, depressive, anxious or schizoid traits

18. Social Cognition Deficits • Deficits in social cognition reported in young adults with schizophrenia • Believed to represent a reduced ability to process context-based information • People with SLP report similar deficits in ‘executive function’ as young people with schizophrenia • Social processing - mentalising (understanding the intentions of others) - also affected in SLP (Moore et al, 2006)

19. Other possible risk factors for SLP • As yet unidentified biological factor  vulnerability towards SLP • Genetic loading for affective disorder • Female sex • Increasing age • Migrant status • Unmarried state and isolation • Specific deficits in social cognition

20. Treatment of SLP Summary: • Pharmacological: No RCTs but observational studies suggest that low dose antipsychotic medication is effective • Psychosocial: Observational studies suggest that engagement with a keyworker and increasing positive social interactions may improve outcome

21. Psychosocial aspects of treatment • Aim to increase positive social interactions - Correcting sensory deficits may reduce the risk of misinterpretation of others’ - Increase social outlets,encourage attendance at hospital/luncheon club - Allocating a keyworker/care co-ordinator to facilitate this and to monitor mental state

22. When to Intervene.. 3 reasons to intervene: When symptoms are causing distress to the point where the person is at risk of • Self-harm • Self-neglect • Retaliation against the ‘perpetrator’ When not to intervene: When the person is refusing treatment AND the risks are low in terms of self or others.