As psychiatrists, we are being pulled in opposite directions between conflicting goals: to reduce health care costs and to provide our patients with the sophistication and specificity of newly available—and more expensive—biological therapies. In the treatment of late-life psychosis, the evidence is impressive and persuasive that atypical antipsychotic drugs are worth the investment.
Atypical antipsychotics should usually be considered first-line therapy for late-life psychosis, though they cost more than the older neuroleptics. Overall, drugs comprise a minor portion of the cost of treating psychosis but may have a major impact on outcomes.1 With their safer side effect profile, the atypicals have enabled many patients with schizophrenia to “reintegrate” and become contributing members of society. Likewise, the use of atypicals can allow older patients with psychotic symptoms to function longer and more productively in their homes and communities.
Table 1
DIFFERENCES BETWEEN LATE-AND EARLY-ONSET SCHIZOPHRENIA
| Characteristic | Late-onset (age 45 and older) | Early-onset (before age 45) |
|---|---|---|
| Gender | More women | More men |
| Type | Paranoid | Varies |
| Positive symptoms | Severe | Severe |
| Negative symptoms | Less severe | More severe |
| Duration of illness | Chronic | Chronic |
| Cognition | Less impaired | More impaired |
| Neuroimaging | Nonspecific changes | Nonspecific changes |
| Antipsychotic dose | Lower | Higher |
| Mortality rates | High | High |
| Premorbid function | Good | Schizoid traits |
Without appropriate treatment of psychosis in younger patients, we know that recurrences and relapses can cause demonstrable brain changes and lead to residual symptoms.2 Older patients have been shown to lose 0.2 “well years” for every year they have psychotic symptoms.3
One illness or many?
Psychotic symptoms can occur in late life for a variety of reasons, and each diagnosis has different implications for patient work-up and treatment. Causes of psychosis in older patients include late-onset schizophrenia, dementia, affective disorder, delusional disorder, and delirium.
Late-life schizophrenia As life expectancy increases, schizophrenia is increasingly being diagnosed in older persons. In a sample of hospitalized patients with schizophrenia, onset of illness occurred after age 50 in 13%, after age 60 in 7%, and after age 70 in 3%.4 The clinical features of schizophrenia may be modified by the concurrent development of dementia. Thus, this reported increase in psychosis after age 50 may be secondary to an increased incidence of dementia, Parkinson’s disease, cerebrovascular events, and neoplasms.
Early definitions of “paraphrenia” and later schizophrenia described delusions and hallucinations that developed without disturbance of affect, with onset in early adult life.5 The occurrence of disorganized behavior and thinking in late life was ascribed to the effects of “senility” or other organic factors.
In 1943, Bleuler6 reported on a series of 126 patients in whom psychosis developed after age 40. In this group, the illness began after age 60 in 4%.
Current diagnostic criteria for schizophrenia do not exclude or categorize individuals on the basis of age. DSMIV does acknowledge a subgroup of patients with “late-onset” schizophrenia after age 45. However, there are important clinical differences in the presentations of the early- and late-onset types (Table 1). For example, even after adjusting for the greater longevity of women, more women than men develop late-onset schizophrenia. Also, compared with the early-onset type, in late-life schizophrenia:
- Premorbid paranoid or schizoid personality traits appear to be much less prominent.
- Patients may have had better occupational functioning and are more likely to have been married.
- Negative symptoms tend to be less severe, although they do contribute to functional decline.
Visual and hearing loss are among the risk factors correlated with late-onset schizophrenia.7 Sensory loss isolates an older person and leads to misinterpretation and misidentification of environmental cues. Other risk factors, in addition to female gender, include cognitive loss, poor social supports, living alone, and alcohol or drug abuse.
Dementia Between 20 and 50% of patients with vascular and mixed dementias exhibit psychotic symptoms.8 Among those with Alzheimer’s dementia, 30% exhibit persecutory delusions.9 Adding to this population are persons with early-onset schizophrenia, who are living longer and can also develop dementia.
While neuroimaging can sometimes aid in diagnosis, abnormalities seen on neuroimaging of patients with psychotic symptoms do not necessarily correlate with cognitive deficits. The clinical significance of these findings is unclear.10,11 Because of differences in therapy, it is important to establish whether the primary diagnosis is dementia or schizophrenia (Table 2).
Affective psychoses Late-life depression and mania are often unrecognized because of atypical presentations. In the elderly, depression may present with withdrawal, mood-incongruent delusions,12 and symptoms that mimic medical illness. Older manic patients may be misidentified as intrusive, hypersexual, or agitated. A high suspicion index, carefully elicited family history, and past psychiatric illness in the patient usually can clarify the diagnosis.
Delusional disorder Suspiciousness and paranoia are common findings in late life, with an estimated prevalence of 4 to 6% in the older population. Patients with delusional disorder show little evidence of cognitive deficits and—unlike those with schizophrenia—continue to maintain a high level of function.13 Delusions are nonbizarre and well systematized, and hallucinations are not a prominent feature.