Psychosis in the elderly

1. Psychosis in the elderly Alistair Burns University of Manchester

2. Psychosis in the elderly Objectives To describe the differential diagnosis of psychosis Explore some of the phenomenology Understand the main aetiological factors Examine the evidence for most effective management

3. Psychosis in the elderly Conclusions To describe the differential diagnosis of psychosis � three main ones, schizophrenia, dementia and depression Explore some of the phenomenology � has diagnostic utility and misidentifications are particularly interesting Understand the main aetiological factors � good evidence for biological underpinning Examine the evidence for most effective management � good evidence for drug treatment but other approaches very important

4. What is psychosis? "�. an individual who lacks insight � and constucts a false environment out of his subjective experiences" Frank Fish Describes a mental state characterised by delusions and hallucinations with a loss of touch with reality and lack of insight

5. Psychosis in the elderly Differential diagnosis Schizophrenia: late onset early onset, grown old Delusional disorder Paraphrenia Dementia Delirium Depression Others � substance misuse, not otherwise specified

6. Psychosis in the elderly Differential diagnosis Schizophrenia: late onset early onset, grown old Delusional disorder Paraphrenia Dementia Delirium Depression Others � substance misuse, not otherwise specified

7. Psychosis in the elderly Historical perspective Kraepelin 1894 dementia praecox � a disorder of emotion and volition paraphrenia � insidious development of a delusional system Kraepelin 1913 changed his mind, complete recovery did occur Bleuler 1911 schizophrenia Mayer 1921 follow up of Kraepelin�s sample, 40% developed dementia praecox Roth and Morrisey 1952 introduced late paraphrenia, a term for patients with schizophrenia with onset after the age of 55 or 60

8. Psychosis in the elderly Historical perspective Bleuler 1943 late onset schizophrenia ie onset after age 40, symptomatology as in schizophrenia, no organic pathology 15% and 17% of two large series had onset after age 40 Felix Post 1966 persistent persecutory states 34/93 schizophrenic syndrome; 37/93 schizophreniform, 22/93 paranoid hallucinosis Late paraphrenia � a heterogeneous disorder

9. Psychosis in the elderly DSM and ICD classifications Late paraphrenia did not survive from ICD9 to ICD 10 Options: schizophrenia, delusional disorder, persistent delusional disorder How are those patients with hallucinations classified? DSM III R � late onset schizophrenia, None in DSM IV Howard et al (2000) late onset schizophrenia very late onset schizophreniform psychosis

10. Psychosis - DSM IV Schizophrenia: Disturbance lasts for at least 6 months including at least 1 month of 2 or more of delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, negative symptoms Schizophreniform: As above but less than 6 months Schizoaffective disorder: Mood disturbance and schizophrenia together Delusional disorder: 1 month of non bizarre delusions

11. Schizophrenia in older people Aims To characterise the neuropsychological deficts in chronic schizophrenia and to document any underlying brain abnormalities Methods 28 elderly schizophrenics, 12 had dementia matched for severity of cognitive impairment with 16 patients with Alzheimer�s disease Results Schizophrenic group more impaired on visuo-spatial tasks MRI showed right sided enlargement in the schizophrenia group Gabrovska V, Scott M, Jeffries S, Thacker N, Baldwin B, Burns A, Lewis S and Deakin B Right hemisphere encephalopathy in elderly subjects with schizophrenia Psychopharmacology 2003 169 367-75

12. Psychosis in the elderly Objectives To describe the differential diagnosis of psychosis Explore some of the phenomenology Understand the main aetiological factors Examine the evidence for most effective management

13. The syndrome of dementia Neuropsychological (Cognitive) amnesia, aphasia, apraxia, agnosia Neuropsychiatric (Non cognitve) Behavioural and Psychological symptoms (BPSD) Psychiatric symptoms Behavioural disturbances Activities of daily living Instrumental Basic

14. Prevalence of neuropsychiatric features of dementia Thought content delusions 20�72% Perceptions misidentifications 23�50% hallucinations 10�20% Affective depression 80% mania 3�15% Personality personality change 90% Behaviour behavioural problems 50% aggression/hostility 20% Sleep/wake cycle disturbance 30�40%

17. Misidentifications 1. People in the person� own home 2. Misidentification of self 3. Signe du mirroir 4. Misrecognition of events on television Capgras syndrome Fregoli�s syndrome Intermetamorphosis

18. Misidentifications Prevalence Review of 10 studies (Molchan et al 1995) 5-31% Rubin et al (1988) 12% TV misidentification 7% mirror sign Merriam et al (1988) 50% misidentified others 40% misidentified places 17% Capgras syndrome Burns et al (1990) 17% phantom boarder syndrome 12% misidentified others 6% TV misidentification 4% mirror sign

19. Misidentifications Capgras syndrome (Capgras and Reboul-Lachaux, 1923) �L�illusion des sosies� - the delusional people (husband, children, herself) had been replaced by identical doubles (imposters) Associated with paranoid, suspicious beliefs Hypo-identification

20. Misidentifications Fregoli syndrome (Courbon and Fail, 1927) People follow the victim about by people who take the form of other people she knew ie familiar people disguised as others Named after an Italian actor, Leopoldo Fregoli, famous for impersonating people A form of hyper-identification

21. Misidentifications Intermetamorphosis (Courbon and Tusques, 1932) Where the physical appearance of some people change radically to correspond to the appearance of others Involves a false recognition of both appearance and identity

22. Psychosis in the elderly Objectives To describe the differential diagnosis of psychosis Explore some of the phenomenology Understand the main aetiological factors Examine the evidence for most effective management

23. Schizophrenia - aetiology Gender differences Women > men ?relative excess of dopamine receptors in women Brain imaging Atrophy midway between that of Alzheimer�s disease and controls Uncoupling of the normal ventricular/cortical atrophy association Neuroreceptors More dopamine receptors in older people Two theories 1. Genetic susceptibility with late life insults eg neuronal loss, low oestrogen 2. Single event later in life eg microvascular disease The Biology of Psychosis in older people Karim S and Burns A J Geriatric Psychiatry and Neurology2003 16 207-12

24. Dementia (Alzheimer's disease) - aetiology Imaging Degeneration of right frontal lobe with delusional misid. on CT scans White matter lesions on CT scans and delusions Hypoperfusion in left frontal area and delusions on SPET Hypoperfusion in both parietal lobes and hallucinations on SPET Molecular Pathology Genetic association between psychosis and 5HT2A/C polymorphisms Genetic association between hallucinations and C102 allele Genetic association between psychosis and DRD 1/2/3 Neuropathology Higher neuronal counts in the presence of hallucinations and delusions Lower neuronal counts in p/hippocampal gyrus with delusional misid. Higher tau protein in entorhinal/temporal cortices with delusional misid. The Biology of Psychosis in older people Karim S and Burns A J Geriatric Psychiatry and Neurology2003 16 207-12 F�rstl H, Burns A, Levy R, Cairns N, Luthert P and Lantos P (1993) Neuropathological Correlates of Behavioural Disturbance in Confirmed Alzheimer's Disease.British Journal of Psychiatry 163 364-368

25. Depression - aetiology Psychotic depression not a distinct subtype in ICD and DSM, but subcategorisation allowed Urinary and serum levels of noradrenaline and dopamine metabolites altered in patients with psychotoc depression O'Brien et al 1997 MRI scans: trend for more deep white matter changes in psychosis Simpson et al 1999 psychotic patients more impaired on card sort and mental processing speed tests psychotic patients more fronto-temporal and third ventricle atrophy on MRI scans The Biology of Psychosis in older people Karim S and Burns A J Geriatric Psychiatry and Neurology2003 16 207-12 O'Brien J et al (1997) Clinical, MRi and endocrinological differences in delusional and non delusional depression in the elderly International Journal of Geriatric Psychiatry 12 211-218 Simpson SW, Baldwin RC, Jackson A and Burns A (1999) The Differentiation of DSM-III-R Psychotic Depression in Later Life from Nonpsychotic Depression: Biological Psychiatry 45 (2) 193-204

26. Psychosis in the elderly Objectives To describe the differential diagnosis of psychosis Explore some of the phenomenology Understand the main aetiological factors Examine the evidence for most effective management

27. Psychosis in the elderly Management Schizophrenia National Institute for Clinical Excellence (NICE) emphasises atypical neuroleptics psychosocial interventions NICE.org.uk

28. Olanzapine + less prolactin elevation - weight gain, diabetes mellitus, anticholinergic side-effects Quetiapine + less EPS - somnolence, postural hypotension Aripiprazole

29. RECOMMENDED DOSES IN THE ELDERLY Drug Initial Dose Max. Dose Clozapine 6.25mg/day 50-100mg/day Risperidone 0.25-0.50mg/day 2mg/day Olanzapine 2.5mg/day 10-15mg/day Quetiapine 25mg/day 80-160mg/day Depot neuroleptics Source Zayas & Grossberg 2002

30. Cochrane antipsychotics in old age psychiatry Studies antipsychotics in Schizophrenia(80% >65years). Search-RCT atypical vs others -Meet Cochrane Criteria No studies met criteria(38 included) Arunpongpaisal et al (2003) Cochrane Library,4,2003.

31. Psychosis in the elderly Management Dementia

32. Risperidone-Stroke Dementia with psychotic symptoms(n=1230)-4 placebo controlled trials. Cerebrovascular events(stroke,TIA) twice as common in active v placebo(4%v2%). Janssen(2003),Wooltorton(2003). In higher doses,linked to diabetes,lipids,obesity.

33. Efficacy of cholinesterase inhibitors in the treatment of Alzheimer�s diseaseTrinh et al 2003 JAMA 289 210-16 Systematic review Directed at neuropsychiatric symptoms and functional impairment Standard search strategy 29 studies Neuropsychiatric inventory/ADAS Non-cog ADL, Instumental ADL

34. Efficacy of cholinesterase inhibitors in the treatment of Alzheimer�s diseaseTrinh et al 2003 JAMA 289 210-16 Neuropsychiatric symptoms 6 trials with Neuropsychiatric inventory (NPI, 0-120) 10 trials with ADAS Non-cog (0-50) Compared to placebo, patients on cholinesterase inhibitors improved 1.72 points (0.87-2.57) on NPI Compared to placebo, patients on cholinesterase inhibitors improved 0.03 points (0.00-0.05) on ADAS No difference between drugs

35. Neuropsychiatric Inventory

36. Alzheimer�s disease Assessment Scale -Non Cognitive

37. Cholinesterase inhibitors: a new class of psychotropic compoundsJeff Cummings American J of Psychiatry 2000 157 4-15 Effect of cholinesterase inhibitors on neuropsychiatric features generally successful visual hallucinations and apathy - good response anxiety, disinhibition, agitation, depression, delusions and aberrant motor behaviour - some response no difference between drugs - class effect

38. Pharmacological interventions for behavioural symptoms 32 trials 15 antipsychotics (4 newer ones) 2 SSRI�s 9 anticonvulsants 6 others 17 RCT�s

39. Sensory stimulation in dementiaBurns A, Byrne J, Ballard C, Holmes C (2002)BMJ 325 1312-1313 Aromatherapy 3 RCT�s all positive, 1 lavender, 1 melissa Bright light therapy 3 RCT�s all positive (?)

40. Agitation in Alzheimer�s disease Teri et al (Neurology, 2000, 55, 1271-8) Comparison of haloperidol, trazodone and behavioural management 149 patients with AD 11 sites in the USA

41. Agitation in Alzheimer�s disease

42. Psychosis in the elderly Management Depression

43. General principles � after Guscott & Grof (1991) Check compliance, dosages, tolerance Review the diagnosis Address medical co morbidity Address reinforcers, eg family. Use a stepped-care approach: dose, length of treatment; when to introduce augmentation; when to give ECT Persist! � Flint & Rifat � 83% success

44. Continuation therapy: Expert Consensus (Alexopoulos et al, 2001) Severe depression One episode � 12 months Two episodes � 24 months 3 or more � at least 3 years Psychotic depression Antipsychotic for 6 months After ECT Non-psychotic � medication Psychotic � medication or maintenance ECT (NICE)

45. Psychosis in the elderly Conclusions To describe the differential diagnosis of psychosis � three main ones, schizophrenia, dementia and depression Explore some of the phenomenology � has diagnostic utility and misidentifications are particularly interesting Understand the main aetiological factors � good evidence for biological underpinning Examine the evidence for most effective management � good evidence for drug treatment but other approaches very important