Psychotic Disorders

Suspiciousness, persecutory delusions, and paranoid delusions occur often in cognitively impaired or emotionally distressed elderly persons. Between 2 and 5% of elderly persons living in the community exhibit excessive suspiciousness and persecutory delusions. As many as 4 to 5% have delusions and hallucinations, and these symptoms are often disabling. However, the prevalence of schizophrenia, as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), is < 1% in the elderly. True schizophrenia begins in adolescence or early adulthood and may persist into late life. Late-onset schizophrenia is called paraphrenia. Identifying psychotic behavior in patients with behavior disorders is discussed in Ch. 41.

Investigators and clinicians generally agree on six relatively distinct clinical entities: abnormal suspiciousness; transitional paranoid reactions; late-life paraphrenia (severe paranoid illness without deterioration of other cognitive or affective processes) or paranoia associated with late-onset schizophrenia; persistence of early-onset schizophrenia; acute paranoid reactions secondary to affective illness; and transient psychoses due to neurologic, toxic-metabolic, or systemic disorders.

Symptoms, Signs, and Diagnosis

Abnormal suspiciousness: Most elderly persons who exhibit abnormal suspiciousness do not have contact with mental health practitioners. However, they often have medical disorders and are seen by a primary care physician or a geriatrician. These patients may have vague complaints of external forces controlling their lives. Occasionally, these beliefs become focal, often directed at their children; eg, they believe their children have deserted them or have plotted to obtain control of their finances or property. Perception of a loss of control, coupled with an inability to evaluate the social milieu, favors the development of abnormal suspiciousness.

Physicians may also encounter suspiciousness associated with dementia and attention deficits. Institutionalized patients with dementia are often suspicious of family and staff members; psychosis due to dementia is, however, uncommon. Their accusations are usually disjointed, unfocused, and unaccompanied by sustained emotional distress. Common complaints concern objects being stolen, medicines being swapped, and attendants misbehaving. Symptoms derive from the patient's inability to organize environmental stimuli and comprehend the often confusing activities of the institution. It is unknown whether an underlying paranoid personality contributes to excessive paranoid behavior in persons with dementia. However, physicians must keep in mind that elderly patients, especially those with dementia, at times are mistreated in long-term care facilities and in hospitals and that suspiciousness may be grounded in fact.

Transitional paranoid reactions: These reactions usually occur in women who live alone; they believe that someone is plotting against them. Social isolation and perceptional difficulties contribute to these reactions. The focus of hallucinations and delusional thinking usually moves gradually from outside the home to inside it, eg, from complaints of noises in the basement and attic to reports of physical abuse or molestation. Hence, a transition can be observed from external threats to violations of property and person.

Paraphrenia: Paraphrenia is not universally accepted as a distinct syndrome. Persons who distinguish the syndrome emphasize that it is primary rather than secondary to an affective illness or to an organic mental disorder. In addition, the gross disturbances of affect, volition, and function characterizing schizophrenia are not prominent. Nevertheless, paranoid delusions and hallucinations almost always occur. Paraphrenia may be chronic, but deterioration to the extent observed in schizophrenia or Alzheimer's disease is not characteristic. The boundaries blur not only between paraphrenia and classic paranoid schizophrenia but also between the transitional paranoid state and paraphrenia.

Patients with paraphrenia often report plots against them, focusing on family members. In contrast with mild suspiciousness, these plots are persistent, extreme, and elaborate. Usually, cognitive impairment is not present. Although the patient is physically independent (ie, diet and hygiene are rarely compromised), social functioning and cooperation with staff members are greatly impaired. Such persons rarely speak for long without referring to the symptoms of concern.

Patients with paraphrenia usually are female, live alone, and have evidence of difficult social interactions earlier in life. In contrast with schizophrenia, these patients are friendly and trusting, especially when they are interviewed in their homes and are not threatened with the diagnosis of a mental disorder. Patients with paraphrenia tend to have a hearing impairment, but the relationship between paraphrenia and hearing impairment is not nearly as strong as some authorities contend.

Early-onset schizophrenia: The symptoms include two or more of the following, each present for most of the time for at least 1 month: delusion, hallucination, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (eg, flattening of affect). Overall, the symptoms must be present for at least 6 months and significantly interfere with social and occupational functioning. Typically, the symptoms become less acute, yet social functioning continues to deteriorate gradually over time. Acute paranoid thinking may accompany an episode of major depression or acute mania. Treating the mood disorder usually eliminates the paranoid thinking in these patients and therefore rules out the diagnosis of schizophrenia.

Elderly persons who have been treated for schizophrenia for years are likely to have adverse effects of antipsychotic drugs (eg, tardive dyskinesia).

Psychotic disorders due to neurologic, toxic-metabolic, or systemic disorders: These include suspiciousness and agitation due to drug intoxication, physical illness, and postoperative psychosis (eg, psychosis occurring among patients in intensive care units). Visual hallucinations occur more often (as in delirium), yet the psychosis may be organized and elaborate (unlike delirium). These disorders are usually transient and resolve with treatment of the underlying cause or spontaneously. In the midst of the disorder, however, acute management is necessary.

Treatment

Nonpharmacologic measures: Health care practitioners (physicians, psychiatric nurses, and mental health social workers) caring for the elderly patient with a psychotic disorder must establish a trusting and supportive relationship. Displays of respect, a willingness to listen to complaints and fears, and availability by telephone are essential. Most elderly patients do not abuse telephone privileges and are generally willing to wait for the physician to return a call.

Health care practitioners should not--at least initially--confront the patient about the lack of reason and false assumptions inherent in paranoid ideation. Such a confrontation is of no value and may disrupt the therapeutic relationship. However, the health care practitioner must not deceive the patient by pretending to agree with paranoid beliefs. Rather, an interest should be expressed in wanting to understand what is troubling the patient and in working together despite a disagreement over the source of the problem. A desirable goal is to develop a level of confidence that allows for an examination of the patient's beliefs.

The health care practitioner must also establish a relationship with key persons in the patient's social environment. Family members are often the first to notice a deterioration in the patient's condition and, therefore, the first to contact the physician when a problem arises. Police officers, neighbors, and pharmacists also can serve as valuable allies. By understanding the patient's situation and recognizing deterioration in status, these persons can contact the physician or family members when appropriate and not overreact. However, health care practitioners must maintain standards of privilege and confidentiality when talking to family members, neighbors, and friends.

Pharmacotherapy: For most patients with psychotic disorders, effective management also requires antipsychotic drugs. The new, atypical antipsychotic drugs (eg, risperidone, olanzapine) are preferred for the agitated or suspicious elderly patient primarily because these drugs have fewer adverse effects (including fewer extrapyramidal adverse effects) compared with conventional antipsychotics (eg, haloperidol, thioridazine). Initial daily oral dosages (in divided doses) are 1 mg of risperidone, 5 mg of olanzapine, 1 to 3 mg of haloperidol, and 10 to 25 mg of thioridazine. Daily doses may be increased significantly (eg, risperidone 5 to 10 mg); however, except in the most acute cases, the lower doses usually suffice. The drugs may be given once daily (at bedtime) in less severe cases.

Choice of drug is usually determined by the adverse effects the physician wishes to avoid. Risperidone is somewhat sedating, has very few anticholinergic effects, but leads to moderate orthostatic hypotension. Olanzapine is as sedating as risperidone, has somewhat more anticholinergic effects, but is less likely to lead to orthostatic hypotension. In contrast, thioridazine is especially troublesome for patients with postural hypotension, and haloperidol may cause significant parkinsonian symptoms. In treatment-resistant patients and in those with severe psychosis, clozapine is a possible choice. There has been little cumulative experience with clozapine in the elderly, although evidence indicates a higher incidence of agranulocytosis.

Most elderly patients are willing to take an antipsychotic drug if they are told that the drug will also help improve sleep and alleviate anxiety. Compliance is often problematic but less so in later life than earlier. Even paranoid persons usually trust their physicians and are willing to comply with therapy. If the elderly patient objects, family members may be able to help. A strong objection to drugs or other interventions may suggest the need for hospitalization if symptoms are severe.

Some elderly patients who have had long-standing schizophrenia may no longer need antipsychotic treatment. At least one trial of discontinuation should be attempted but only when close supervision is possible.