Psychosis in the Elderly

Anne M. Hassett, David Ames, Edmond Chiu

• Publisher: CRC Press
• Year: 2005
• Print ISBN: 9780367392635
• eBook ISBN: 9781135409586
• Topic: Medicina
• Subtopic: Geriatria

Across the spectrum of psychopathology in later life, psychotic symptomatology has been the most neglected, and although literature in this area is increasing, this is the first book to address the need for an overarching framework to examine and understand late-life psychotic phenomena. Exploring the practical and ethical issues that arise when ma

chapter 1
Historical perspective

Mary V.Seeman and Dilip V.Jeste

Introduction

A small percentage of elderly individuals must, since time began, have felt spied upon by neighbors, cheated by families, invaded by intruders. According to epoch and place of birth, these expressions of what is now called delusional thinking were either dismissed as eccentricity, forgiven as frailty, or heeded as revelation. They almost certainly were not considered worthy of medical study until approximately the end of the nineteenth century. Since then, the classification of such symptoms in the elderly has varied, depending on how they were understood. Psychiatric classifications are never static but evolve over time, subject to changing concepts of health and disease. Vogues in diagnosis are always influenced by shifting theories of causation. Even the expression of symptoms, both in form (disjointed or coherent) and content (touched by God or hexed by evil spirits) varies over time periods. Social and historical forces inevitably put their stamp on symptoms and diagnoses (Markova and Berrios, 1995; Berrios, 1999; Zalewski, 1999).

Modern psychiatric nomenclature probably began in the late eighteenth century when the term ‘neurosis’ was first introduced. Neurosis referred to diseases of nerves and muscles and was initially attributed to a physical cause. The term ‘psychosis’, first used in the mid-nineteenth century, originally referred to a ‘diseased mind’, a subgroup of the neuroses. By 1900, these two terms had taken on new meaning. Psychosis was now considered as a class apart, the outcome of brain pathology; neurosis was thought to originate in psychological conflict (Beer, 1996). As these changes were occurring, life expectancy began to rise and, over the course of the twentieth century, this continued dramatic increase in lifespan changed the social and cultural meaning of growing old. Until the end of the nineteenth century, the old were seen as preparing for death and it was chaplains, not doctors, who were called to care for them. By the late 1940s, old age had become a specific social and medical problem requiring professional help. When medicine and psychiatry finally turned their attention to diseases of the old, Foucault derided this new turn of events and called it the ‘medicalization of old age’, medicine arrogantly appropriating the terrain of sociology (Gockenjan, 1993; Hirshbein, 2001).

The definition of old age has changed over the years. One hundred years ago, those over 60 were considered elderly. This point of division was based on French and German statistics showing a decline in function beginning at that age (Kirk, 1992). Today, that line would be drawn later and very likely at a different age in different parts of the world (Stearns, 1981).

Late-life psychosis

Psychosis of old age at the beginning of the twentieth century thus meant a psychotic illness first emerging after age 60. The various categories of psychotic illness, quite apart from onset age, have undergone considerable change and discussion over the last 100 years (Jablensky, 1999; Eyler and Jeste, 2002). The distinction between the two major forms of psychosis, schizophrenia (dementia praecox) and bipolar disorder (manic-depressive insanity), proposed by Kraepelin in 1896, has been vigorously debated (Berrios and Hauser, 1988). The debate about nosology is most vigorous when applied to the elderly, among whom psychotic features are seen in conjunction with schizophrenia, affective illness, delusional disorder, delirium, and dementia. The onset of delusions and hallucinations in old age can arise de novo or can be associated with pre-existing mood disorder or newly acquired medical disorder or dementia. Whether the syndrome fits best under the rubric of schizophrenia or delusional disorder has been the subject of considerable controversy since 1955 (Roth, 1955; Karim and Burns, 2003).

The history of paranoia/paraphrenia

The ancient Greek word ‘paranoia’ (para noos) means ‘beyond mind’. It was used in early times to describe madness. In the eighteenth century, it was a medical umbrella term for both mood disorders and dementia. The first systematic description of paranoid features with onset in later life was published under the title of Involutional Paranoia (Kleist, 1992). Kleist acknowledged that the clinical features of this disorder were very similar to those described by Kahlbaum in 1863 as paraphrenia.

An aside on the etymology of paraphrenia: When the heart was thought to be the seat of emotion, the term ‘phrenum’ (diaphragm) was used to describe the restraint placed on the heart. Paraphrenia thus meant ‘beyond restraint’ as in phrenetic. As the brain was ultimately understood to control emotion, ‘phrenum’ began to refer to the casing of the brain.

In the eighth edition of his 1896 textbook, Kraepelin subdivided paraphrenia into four forms:

1. paraphrenia Systematica: an insidious development of delusions of persecution and exaltation
2. paraphrenia Expansiva: exuberant ideas of grandiosity and mild excitement
3. paraphrenia Confabulaloria: falsifications of memories
4. paraphrenia Phantastica: extraordinary, incoherent and changeable delusional ideas.

The concept of paraphrenia has always been controversial. By 1921, German psychiatry considered paraphrenia a form of schizophrenia while psychiatrists in the UK considered it a form of delusional disorder. ‘Late paraphrenia’ was introduced in the mid-1950s as the term to be used when these conditions first began over age 60 (Roth, 1955). The term was still present in the ICD-9 (WHO, 1980), but is not included in current diagnostic classifications (Naguib, 1991; Berrios, 2003). Using ICD-10 (WHO, 1992) diagnostic criteria, about 60% of those previously diagnosed with paraphrenia meet criteria for schizophrenia, 30% for delusional disorder and 8% for schizoaffective disorder. Because there seem to be no significant differences between the patients in the ICD-10 schizophrenia and delusional disorder groups in terms of age at symptom onset, sex ratio, response to treatment, single status, the presence of insight or sensory impairment, the usefulness of such distinctions in ICD-10 and DSM-IV (American Psychiatric Association, 1994) when applied to the elderly population is questionable (Howard et al, 1994).

Risk factors for old age psychosis

Not only is there continuing debate about the nosological status of late-onset psychosis, but there is also controversy about the particular risk factors that are associated with this entity (Jeste et al, 1995, 1997). Early cognitive decline is frequently seen in these patients, but there is no clear relationship with a dementing process. Sensory impairment (Prager and Jeste, 1993), social isolation (Weeks, 1994), and a family history of schizophrenia (Almeida et al, 1992, 1995a) have all been associated with late-onset psychosis, but they appear to exert, at most, a nonspecific influence. Women exceed men in late-onset psychosis samples by 6–10-fold and this imbalance is not fully explained by the greater longevity of women (Castle and Murray, 1993; Almeida et al, 1995b; Lindamer et al, 1997). Although imaging studies have pointed to brain abnormalities, these changes appear subtle and generally similar to those found in patients with illness onset in earlier life (but late-onset cases show more signal hyperintensities than controls) (Corey-Bloom et al, 1995; Sachdev et al, 1999).

Symptoms

Late-onset paranoid disorders have two main symptom characteristics: a preoccupation with the transgression of personal space (partition delusions), and delusions of personal injury (robbery, jealousy, infestation). These phenomena are present in over 50% of ‘late paraphrenias’ compared with a rate of 20% in schizophrenia of young adult onset. Social isolation and cognitive deficits have been cited as contributory (Howard et al, 1992).

The controversy and the attempts to resolve the controversy

Since the early 1960s, discussions about the nature of late-onset psychoses have focused on two conflicting views:

1. that they are the expression of schizophrenia in the elderly
2. that they are genetically different from schizophrenia and arise from the complex interaction of various vulnerability factors associated with old age.

Besides the confusion between delusional disorders and schizophrenic disorders in old age, there is also the confusion between late-life paranoid disorders and Alzheimer’s disease (AD), as both show some similar brain changes, although to different degrees (Förstl et al, 1994). Approximately 50% of patients with AD experience delusions or hallucinations within 3 years of clinical diagnosis (Jeste and Finkel, 2000; Paulsen et al, 2000). Psychosis is more likely to present during intermediate stages of dementia than in very early or very late stages. Another confusion arises between delusional disor-ders and affective disorders, first noted by Kraepelin, particularly between mania and ‘paraphrenia confabulans’. Since Kraepelin, German psychiatry has focused on the similarities of symptoms and course of these two entities, much as it has focused on the similarities between schizophrenia and paranoid disorders of old age (Riecher-Rössler et al, 1995). French psychiatry, on the other hand, considers paraphrenia to be the end product of a prior psychotic disorder, such as mania (Sarfati et al, 1997). Adding to the complexity of sorting out nosological entities are the co-morbid physical illnesses, social isolation, sensory deficits, cognitive changes, effects of polypharmacy, and substance abuse often suffered by the elderly (Targum and Abbott, 1999).

To resolve controversies such as these, a two-day international meeting was held at Leeds Castle outside London in July 1998 to attempt a consensus on terms. The debates at the meeting plus a review of the literature achieved the following agreement: The term paraphrenia is best dropped. Nonorganic, nonaffective psychoses that have a first onset in later life can be divided epidemiologically into two categories: (a) late-onset schizophrenia (illness onset after 40 years of age but otherwise indistinguishable from schizophrenia starting at an earlier age) and, (b) very-late-onset schizophrenia-like psychosis (onset after 60 years). This latter group is generally associated with a somewhat different symptom profile and does not seem to have genetic risk factors for schizophrenia (Howard et al, 1997, 2000; Roth and Kay, 1998; Hafner et al, 2001; Palmer et al, 2001; Howard and Reeves, 2003).

Epidemiology

For the so-called ‘functional’ psychoses of late life, epidemiological information comes from two sources: studies of persons who have reached psychiatric services and surveys of elderly persons sampled from the general population. Except in terms of numbers affected, there is no notable divergence in the information obtained from clinical series and from population-based surveys. Late-life-onset psychotic symptoms are present in nearly 10% of patients over 65 attending a psychogeriatric clinic and are positively associated with increasing age. About three-quarters of patients are women, usually in their seventies. A study designed to identify prospectively patients suffering from very-late-onset schizophrenia-like psychosis (VLOSLP) recently enrolled 21 VLOSLP patients (15 women, 6 men; mean age, 78.1 years) and 21 age-and gender-matched elderly schizophrenia patients. The VLOSLP group was characterized by higher education, a higher rate of marriage, more pronounced cerebellar atrophy, and better response to treatment with risperidone (Barak et al, 2002).

Psychosocial issues

Despite speculations about the influence...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contributors
• Foreword
• Acknowledgments
• Introduction
• Chapter 1: Historical Perspective
• Chapter 2: Defining Psychotic Disorders In an Aging Population
• Part I: Late-Onset Schizophrenia
• Part II: Management of Early- And Late-Onset Schizophrenia
• Part III: Other Psychotic Disorders In the Elderly