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Very Late Onset Schizophrenia Like Psychosis Bruce Allen Old Age Psychiatrist Hanoi October 2012 Outline: Case History Historical background Epidemiology International Consensus: ‘Very Late Onset Schizophrenia Like Psychosis’ Is late onset schizophrenia due to dementia? Management Case History: 71 year old divorced woman, retired clerk, lives alone in rented accommodation son who lives close by 10 year history of persecutory delusions and auditory hallucinations Landlords entering her flat, bugging her flat, taking photos and video through the ceiling Hears landlords speaking about her actions Cardboard over shower, dresses under several dressing gowns No insight Another Case History: Mrs MF Looks after flat well Always well groomed No difficulties with day to day function Cognitive function normal Goes out with friends five days per week, dinner with son’s family twice a week, enjoys contact with grandchildren Auditory hallucinations have settled with risperidone 0.5 mg at night, remains delusional, won’t increase the dose due to ‘side effects’ ‘Late Paraphrenia’ 1952 Roth and Morrisey: Elderly patients Female preponderance Well organized paranoid delusions +/- Hallucinations Preserved personality and affect Do not deteriorate cognitively or neurologically Patients they believed had schizophrenia of onset after 55 or 60 years Descriptive term to distinguish these patients from those with chronic schizophrenia Roth: The Natural History of Mental Disorder in Old Age: (1955) Mortality Study: Follow-up study of 450 patients 46/450 diagnosed with Paraphrenia, 34/46 female Mortality significantly lower than arterio-sclerotic psychoses Concluded Late Paraphrenia is a separate disease from arterio-sclerotic psychoses One patient with Paraphrenia developed dementia Kay and Roth: (1961) Five year follow up 99 cases Deafness (40%) 8% had focal cerebral disease Psychosis remained chronic A form of schizophrenia, but aetiology multifactorial Psychotic Symptoms in Community Living Elderly People Paranoid Delusions: 0.1% to 8.9% prevalence rates (Henderson and Kay 1997, Christenson and Blazer 1984, Forsell and Henderson 1998) Most have dementia If cognitive impairment controlled: Female predominance Social isolation (cause or effect?) ? Sensory impairment Hallucinations and/or Delusions at 85 (Ostling and Skoog 2002) Prevalence rate: 10.1% (no dementia) More likely to develop dementia at years Key Informant twice as likely to report psychotic symptoms as interview by psychiatrist Epidemiology Schizophrenia (Castle and Murray 1993) Epidemiology Schizophrenia (Castle and Murray1993) Phenomenology Earlier Onset Schizophrenia: Formal thought disorder Passivity phenomena / catatonia Thought interference Negative symptoms Very Late Onset Schizophrenia: Delusions (elaborate and organised) Persecutory (93% cf 62%) – ‘elaborately organised’ Partition delusions (50%) Tormented by machines, X-rays, other special means (22%) Hallucinations Auditory (85%) – any form Visual (22%) Somatic (17%) Olfactory (10%) Partition Delusions People, animals,objects, radiation Pass through an impermeable barrier Up to 70% of Late Paraphrenia vs 10% Early Onset ‘Very Late Onset Schizophrenia Like Psychosis’: International Consensus (2000) 17 representatives of basic science and clinical schizophrenia research, all continents Met days July 1998 Reviewed epidemiology, phenomenology, pathophysiology, aetiology and treatment Consensus statement International Consensus Statement Onset: Late Onset Schizophrenia: Onset after 40 years Very Late Onset Schizophrenia Like Psychosis: Onset after 60 years Very Late Onset Schizophrenia Like Psychosis: Female preponderance Sensory impairment and social isolation Less thought disorder and affective blunting More visual hallucinations No difference in cognitive deficits (? Milder in later onset) No differences in brain imaging findings Considered distinct from schizophrenia Is Very Late Onset Schizophrenia Like Psychosis due to Dementia? Consensus Group: No evidence that it is due to dementia Schizophrenia is associated with cognitive deficits at all ages Impaired executive function, learning, motor skills and verbal ability No difference in cognitive function to earlier onset Schizophrenia Brain imaging findings are similar regardless of onset age (in contrast to increased white matter hyperintensities in late onset affective disorders) Clinical and Cognitive Diversity of Psychotic States in Late Life (Almeida et al 1995) 47 subjects with ‘late paraphrenia’ 33 normal controls Cluster Analysis of Cognitive Findings: Cluster 1: ‘Functional’ Circumscribed executive impairment, Positive psychotic symptoms, Positive family history schizophrenia (non significant) Cluster 2: ‘Organic’ Generalised cognitive impairment Less complex psychotic symptoms More soft neurological signs Negative symptoms (still relatively uncommon) Schizophrenia With Onset After 50 (Sachdev and Brodaty et al 1999) Subjects: 27 Early Onset Schizophrenia (onset before 35 years) 30 Late Onset Schizophrenia (onset after 50 years) 34 Controls Recruited from local mental health service Inclusion criteria: DSM IIIR Schizophrenia No neurological disease or drug abuse Mini Mental State Examination > 19 Informant available Five Year Follow Up of Late Onset Schizophrenia: (Sachdev and Brodaty et al 1999) Late Onset Schizophrenia: significantly worse outcome on most measures Dementia more likely if Institutionalised at a younger age Lower function Mini Mental State Examination score declined by 6.5 points (controls stable) developed dementia, predominantly Alzheimer’s (no controls) Worse Mini Mental State Examination, poorer daily function, larger ventricles and white matter changes at baseline However, 50% were cognitively stable and their Global Assessment of Function had improved with treatment Summary: Is Very Late Onset Schizophrenia Like Psychosis Associated with Dementia? Studies show increased, intermediate and normal rates of ‘organic deterioration’ But – diversity diagnostic criteria, short follow-up periods, heterogeneous populations A subgroup may be in the early phase of a dementing illness A subgroup show no cognitive decline over followup Dementia, delirium and affective disorders are more common causes of psychosis in the elderly Treatment: Cochrane 2009 Antipsychotic treatment for elderly people with late onset schizophrenia: Trials where 80% participants > 65 Recent (within years) 38 trials (65 papers) Most involved elderly people with chronic schizophrenia Conclusion: No trail based evidence, Prescribing based on clinical judgement and habit Management Principles: Therapeutic alliance Isolated, alienated neighbours, GP and friends Often lonely May accept opportunity to ventilate re persecution Establish regular visits, encourage to reserve discussion of delusions to mental health teams Re-housing does not work Antipsychotic Medications Probably more modest response than Early Onset Schizophrenia Depot antipsychotics probably more effective Use lower doses Antipsychotics in the Elderly Increased sensitivity: Increased side-effects: Tardive dyskinesia (risk 5-6x higher with typicals) Increased rates cognitive decline (dementia) Increased risk of CVA (dementia) Increased relative risk death all causes (dementia) Very Late Onset Schizophrenia Like Psychosis – Consensus: Treatment Mainstay of treatment: antipsychotics Start low and increase dose slowly 10 – 50% of doses for Early Onset Schizophrenia Very low dose depot antipsychotics for compliance Atypical antipsychotic medications preferable in view of Extra Pyramidal Side Effects and Tardive Dyskinesia Take care with clozapine (more side effects) Conclusions Research largely over the last 30 years Can be difficult to distinguish who will develop dementia on initial presentation Aetiology not clear Gross degenerative changes are not present Arguments unresolved over whether it should be best classified with Schizophrenia or whether it is a separate disorder in it’s own right Symptomatic improvement with antipsychotics
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