Late-Onset Psychosis

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0SPECIAL ARTICLE0 Psychiatry Investig 2007;4:9-12 ISSN 1738-3684

Byeong Kil Yeon, MD, PhD, ObjectiveㅋAlthough psychotic disorders usually manifest in young adulthood or middle age, Narei Hong, MD some psychotic patients present psychotic symptoms for the first time in late life. The concept and diagnosis of late-onset psychosis have changed over the years. The authors review the clinical Department of Psychiatry, Hallym University College of Medicine, features, epidemiology and treatment of late-onset psychosis, with particular emphasis on late- Hallym Medical Center, Seoul, Korea onset schizophrenia. MethodsㅋThe authors conducted a MEDLINE literature review. Reviews, textbooks and some clinical studies about late-onset psychosis which were published in the literature were reviewed. ResultsㅋAlthough, in general, patients with late-onset schizophrenia have similar symptoms to those with early-onset schizophrenia, they are more likely to complain of hallucinations, persecutory delusions and partition delusions, and they are less likely to display formal thought disorder, affective flattening or blunting than their earlier-onset counterparts. Like early-onset schizophrenia patients, late-onset schizophrenia patients exhibit nonspecific structural changes in the brain. Although the exact prevalence of late-onset schizophrenia is not yet known, the 1-year prevalence rate of late-onset schizophrenia was found to be less than 1%. There is no trial-based evidence to help guide the choice of drug, however a number of special considerations are necessary when managing elderly patients. ConclusionsㅋIn the past few years, late-onset psychosis has begun to arouse the interest of psychiatrists, with research into late-onset schizophrenia being a relatively recent endeavor. The diagnosis and treatment of psychotic symptoms in elderly patients requires more than just extrapolation from that of young patients. There is a necessity for further researches involving Korean late-onset psychosis patients.

KEY WORDS: Geriatric psychiatry, Psychotic disorders, Schizophrenia, Aged.

Psychiatry Investig 2007;4:9-12

Introduction

Psychotic disorders such as schizophrenia and mood disorders with psychotic features usually manifest in young adulthood or middle age, and late-onset psychosis is comparatively rare. However, some psychotic patients definitely present psychotic symptoms for the first time in late life. Furthermore late-onset psychosis has different characteristics from those of the more common early-onset psychosis. As the population ages, the number of older persons with a major psychiatric disorder is expected to increase. As a result late-onset psychosis will likely cause more Correspondence serious problems than before, and consequently research into this disorder is on the Narei Hong, MD increase. Department of Psychiatry, Hallym University College of Medicine, The initial studies of late-onset schizophrenia were conducted by Manfred Bleuler, Kangdong Sacred Heart Hospital, who described it as being similar to early-onset schizophrenia, except that the age of 445 Gil 1-dong, Gangdong-gu, onset was over 40 years.1 He personally examined 126 patients whose illness began Seoul 134-701, Korea after the age of 40 years. These late-onset cases constituted 15% of the schizophrenia Tel +82-2-2224-2266 Fax +82-2-487-0544 patients he examined; 4% of the patients experienced onset after 60 years old. About E-mail [email protected] 50% of the patients with late-onset schizophrenia had symptoms that were indisting-

Late-Onset Psychosis uishable from those of the patients with early-onset sch- Results izophrenia.2 Martin Roth and colleagues introduced the idea that late-onset schizophrenia could be a distinct Clinical features entity, and adopted the term “late paraphrenia” for the The clinical presentation of older persons with schi- group of patients whose onset of the disorder occurred zophrenia differs somewhat from that of younger persons. after the age of 60. These patients were generally women At first, Bleuler found some differences in the symptom with sensory deficits, who had no family history of schi- profile between late-onset and earlier-onset schizophre- zophrenia and presented with delusions and hallucina- nia. Just over 50% of the late-onset patients had “para- tions.3 The concept of late paraphrenia was adopted in phrenia-like, depressive-anxious catatonic or confused the ninth edition of the International Statistical Classi- agitated” symptoms. The remainder had symptoms similar fication of Diseases and Related Health Problems (ICD-9), to those of the earlier-onset patients, but with less affe- and was said to include female preponderance, abnormal ctive flattening and a more favorable prognosis.1,5 premorbid personality and social functioning, and dea- Nowadays, although a diagnosis of schizophrenia with- fness.4,5 out an onset specifier is acceptable, differences between The age of onset criteria for schizophrenia in the Dia- early- and late-onset schizophrenia have been identified. gnostic and Statistical Manual of Mental Disorders (DSM) Although, in general, late-onset patients have similar sy- have changed over the years. The first and second edi- mptoms to those of early-onset schizophrenia, they are tions of the DSM (DSM-I and DSM-II) did not specify more likely than their earlier-onset counterparts to com- the age of onset criteria for schizophrenia. Unlike in the plain of visual, tactile, and olfactory hallucinations, per- previous DSM editions, the DSM-III criteria restricted secutory delusions and partition delusions (delusions that the diagnosis of schizophrenia to those with symptom people, substances, or forces are entering through the onset before age 45, and DSM-III-R had a separate cate- walls from next door), and they are less likely to display gory for patients whose illness emerged after age 45. formal thought disorder, affective flattening or blunting.8 Since the ICD-10 and DSM-IV, the criteria for schizo- Jeste et al. reported that thought disorder and affec- phrenia do not contain separate codeable diagnoses for tive flattening were less prevalent in patients whose illness late-onset schizophrenia. However DSM-IV and DSM- began after age 45 years,9 and in their more recent study, IV-TR mention differences between cases of schizoph- they found better premorbid functioning and a higher renia with onset after 45 years compared to those with prevalence of paranoid ideation in patients with late-onset earlier onset.1,6,7 schizophrenia.10 As mentioned above, late-onset psychosis has become Schizophrenia is commonly associated with mild-to- the center of concern of geriatric psychiatrists, and it is moderate neuropsychological deficits. Some studies found important for those who treat the elderly patients with that patients with late-onset schizophrenia also had cog- psychosis to be concerned about late-onset psychosis and nitive deficits, particularly in their executive functions.10-12 to have a thorough knowledge of this disorder. Folsom et al. reported that the patients’ neuropsychological In a broad sense, late-onset psychosis includes not functioning remained stable over follow-up periods of only late-onset schizophrenia but also the other psychotic up to 5 years or more, in elderly patients with both early- disorders-affective psychoses (manic or depressive), pa- onset and late-onset schizophrenia.13 ranoid psychoses without hallucinations (delusional dis- Harris described a typical patient with late-onset schi- orders) and those psychotic affective and paranoid syn- zophrenia as having been married, held a job or been a dromes that may arise in association with demonstrable homemaker, and functioned in the community and wi- or suspected cerebral disease in the absence of a diagno- thin the family. It was said that such a patient might sable dementia syndrome in elderly patients. However, have a history of mild schizoid or paranoid personality in this article, the authors give priority to late-onset sch- traits, and that prodromal symptoms and a gradual decline izophrenia. This article briefly reviews the clinical feat- in functioning might develop, followed by delusions (us- ures, epidemiology and treatment of late-onset psychosis. ually complex and often bizarre) and hallucinations.14 The delusions and hallucinations in late-onset psychosis Methods are often florid and fantastic, and are accompanied by quarrelsome or abusive behavior, repeated complaints to The authors conducted a MEDLINE literature review. the police, or self-seclusion, and lack of insight. Delusions Reviews, textbooks and some clinical studies about late- of persecution and reference are most common, but delu- onset psychosis which were published in the literature sions of control, hypochondriasis and jealousy also occur.15 were reviewed. In Korean investigation, patients with late paraphrenia

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BK Yeon & N Hong were found to have a more paranoid personality trait, ni- emergence of symptoms and contact with medical ser- hilistic delusion and hypochondriasis, and affective sym- vice34 between male and female. ptoms than patients with early onset-schizophrenia.16 As in the case of early-onset schizophrenia, there have Treatment been some computed tomography (CT)17 and magnetic There have been few controlled trials of the use of resonance imaging (MRI)18 studies which reported fi- antipsychotic medications in late-onset schizophrenia, ndings of nonspecific structural changes (e.g., higher and there is no trial-based evidence to help guide the ventricle-to brain ratio and third ventricle volumes) in choice of drug. Therefore it is likely that clinicians have the brains of patients with late-onset schizophrenia. made the choice of antipsychotics based on clinical ju- However the thalamic volume of late-onset schizoph- dgment and their prescribing patterns.35 renia patients has been reported to be larger than that of Although there are no medications specific to late- early-onset schizophrenia patients and not significantly onset schizophrenia, a number of special considerations different from that of unaffected subjects.19 In functional are necessary when managing elderly patients. App- imaging studies, regions of hypoperfusion in the frontal roximately 80% of the elderly have at least one chronic and temporal areas,20 the left posterior frontal and bi- serious physical illness and may be receiving multiple lateral inferior temporal areas,21 and bilateral frontal and drug therapy. Because of age-associated cognitive im- temporal lobes22 have been reported. pairment, elderly patients may not only forget to take their medication, but also take the wrong doses or use Epidemiology inappropriate dosing intervals. Elderly patients have a Late-onset psychosis is comparatively rare and data greater risk for adverse effects on account of age-related for this disorder are scarce. Also, the exact prevalence pharmacokinetic and pharmacodynamic changes.36 It is of late-onset schizophrenia is not yet known. The point important that drug treatment should be started at very prevalence of paranoid ideation in the general elderly low doses and that increases in dose should be made population has been estimated to be 4-6%, but most of slowly in elderly patients. these patients will also have dementia.23-25 In the United Typical late-onset patients will respond to dose amo- Kingdom, some studies found that late paraphrenia con- unts that are about one-quarter to one-half those given stituted 5-10% of admissions to mental hospitals.15,26,27 to early-onset schizophrenia patients (i.e., approxima- Harris et al. suggested that the proportion of schizoph- tely 200 mg chlorpromazine equivalents per day37).8,36 renia patients whose illness first emerged after the age The risk of extrapyramidal side-effects (EPS) and of 40 was approximately 23.5%,28 and 13% of patients tardive dyskinesias (TD) is known to be particularly high with schizophrenia were reported to have experienced in elderly patients. Jeste et al. reported that the risk of onset in the fifth decade, 7% in the sixth decade and 3% TD in older outpatients in high, even with a relatively in later decades. The 1-year prevalence rate of schizo- short treatment course of low dose typical antipsycho- phrenia in persons 45 to 64 years of age was found to be tics.38,39 In elderly schizophrenia patients, no significant 0.6% in one investigation, and another study reported a differences were demonstrated in the 1-year incidence rate of 12.6 per 100,000 per year for new-onset schi- of TD among early-onset schizophrenia and late-onset zophrenia. In elderly patients with schizophrenia, appro- schizophrenia patients were demonstrated.7 ximately 90% were found to have the early-onset form, Psychosocial and behavioral approaches are also im- and the remaining 10% to have late-onset schizophrenia.1 portant for patients with schizophrenia, although their In Korea, there have been few studies about late-onset role in the management of patients with late-onset schi- psychosis. In one epidemiological survey in a rural area, zophrenia remains to be investigated. the prevalence of late-onset psychosis was estimated to be 0.05%.29 Discussion Late-onset schizophrenia is two to ten times more common in women than in men.1,14,30,31 These findings, Over the past century, studies about schizophrenia coupled with the higher incidence rates of early-onset primarily involved young adult patients. During some schizophrenia in men, have led to the hypothesis that periods, schizophrenia was considered to be a disease estrogen-mediated dopaminergic inhibition may protect that only young adults suffered from. In the past few years, younger women from schizophrenia. However, these late-onset psychosis has begun to arouse the interest of robust findings of a gender difference are not readily psychiatrists with research into late-onset schizophrenia explicable in terms of variations in the care-seeking and being a relatively recent endeavor. societal role expectations32,33 or in the delay between the Late-onset psychosis has a somewhat different symptom

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